Annals of Intensive Care最新文献

Acute kidney injury and other organ dysfunction in the setting of heart failure are primarily determined by a low cardiac output status and venous congestion, which is a sequence of increases in heart filling pressures. Early point-of-care ultrasound assessment of the inferior vena cava, lung ultrasound for pulmonary congestion, and focused echocardiography have become increasingly used in the bedside evaluation of congestive heart failure and assessment of the left ventricle. The congestion disrupts venous outflow in abdominal organs, most notably the kidneys and liver, and can be noninvasively evaluated with Doppler ultrasound, known as the venous excess. Such flow abnormalities have been repeatedly linked to congestive organ dysfunction and poorer clinical outcomes. In this review, we outline a thorough, bedside approach to assessing venous congestion using Doppler imaging. Venous Excess Ultrasound (VExUS) is an emerging protocol that offers a point-of-care ultrasonic method for grading systemic congestion and tailoring diuretic management. The purpose of this review is to evaluate VExUS's potential applications and critically appraise current evidence on its effectiveness in directing decongestive therapy for patients with acute decompensated heart failure. In conclusion, multiple Doppler venous congestion assessment emerges as a promising, noninvasive tool for the instantaneous assessment of organ congestion in cardiorenal syndrome, helping in the management of fluid and diuretic administration. Its accuracy, however, depends on the sonographer's proficiency. Larger-scale studies are needed to confirm their applicability in clinical practice.

Intravenous lipid emulsions (ILE) were first proposed in 1998 as a treatment for bupivacaine-induced cardiac arrest. Since then, their use has expanded to include poisonings by various lipophilic drugs such as tricyclic antidepressants, calcium channel blockers, and antipsychotics. This 2025 narrative review explores the evolving pathophysiological mechanisms of ILE therapy, including the lipid sink and lipid shuttle theories, as well as non-scavenging cardiotonic effects such as membrane stabilization, mitochondrial support, and modulation of vascular tone. It summarizes recent findings from randomized controlled trials, cohort studies, animal models, and case registries. While clinical trials demonstrate potential benefits-particularly in tramadol, clozapine, and organophosphate poisonings-mortality reduction remains unproven, and evidence is limited by study heterogeneity and low methodological quality. Adverse effects, although rare, include acute pancreatitis, interference with laboratory testing, and fat overload syndrome, especially at high infusion volumes. Current guidelines recommend ILEs as a first-line treatment for local anesthetic systemic toxicity and as a second-line option in life-threatening poisonings involving other lipophilic agents. However, significant uncertainty remains regarding optimal indications, dosing strategies, and long-term safety. High-quality, multicenter studies and updated registries are needed to refine these recommendations and clarify the role of ILEs in clinical toxicology.

Background: No study has evaluated the inspiratory effort in patients with obesity immediately after extubation according to the noninvasive ventilatory support used. We aimed to determine, in critically ill patients with morbid obesity, whether Non Invasive Ventilation applied with facial mask with Pressure Support above Positive End-Expiratory Pressure (PSV-PEEP) may reduce patient inspiratory efforts to a greater extent than Continuous Positive Airway Pressure (CPAP) after extubation.

Methods: We conducted a post-hoc analysis based on data from a physiological study involving consecutive patients with morbid obesity prior to extubation. Flow, airway, esophageal, and gastric pressure signals were then recorded 20 min after extubation under three distinct conditions: (1) standard oxygen, (2) CPAP and (3) PSV-PEEP. Inspiratory efforts were assessed by calculation of the trans-diaphragmatic pressure (Pdi) and work-of-breathing (WOB).

Results: Fifteen patients with mean body mass index of 45 kg/m² (± 8 kg/m²) were enrolled. WOB and Swing Pdi were lower with PSV-PEEP than with CPAP and standard oxygen respectively 5.3 [3.6-6.0] vs 8.4 [7.4-10.0] and 14.9 [11.1-22.1] J/min (p < 0.001), and 5.9 [4.0-7.8] vs 11.4 [10.1-13.1] and 19.6 [18.5-23.6] cmH2O (p < 0.001). We also observed a significant decrease of respiratory rate (RR) and RR/V_T (tidal volume) ratio with the use of PSV-PEEP (24.4 [21.9-27.7] breaths/min and 65.7 [45.1-78.5] min/mL, respectively), and with the use of CPAP (24.6 [24.1-34.5] breaths/min and 75.3 [57.2-108.0] min/mL), compared with standard oxygen (29.0 [24.2-34.9] breaths/min and 81.1 [73.5-108.9] min/mL), p < 0.05.

Conclusion: In critically ill post extubation patients with morbid obesity, both PSV-PEEP and CPAP reduced the inspiratory effort indexes including inspiratory work-of-breathing, traducing an unload of inspiratory muscles. This effect was more important when PSV-PEEP was used in comparison to CPAP, suggesting a more pronounced effect of inspiratory muscle unloading.

Background: Fluids are a key component of shock resuscitation. Nevertheless, their microvascular effects are complex. In fluid responsive patients, fluids may increase tissue perfusion because of the increase in cardiac output. Since shock states are characterized by a partial loss of the coherence between systemic hemodynamics and microcirculation, the increase in cardiac output does not guarantee improvements in tissue perfusion. Furthermore, the administration of fluids carries risks of hemodilution and tissue edema that can dampen microcirculation. Regarding this, colloid solutions have some theoretical advantages and experimental support. Despite its relevance, few clinical studies have evaluated the effects of fluids on sublingual microcirculation-the more clinically accessible territory for videomicroscopy. This review analyzes physiological bases and experimental and clinical evidence about the complex microvascular effects of fluids.

Main text: We found eight observational and four controlled trials carried out on critically ill and surgical patients addressing the effects of fluids on sublingual microcirculation. Most showed that fluid resuscitation can improve microcirculation, especially in the presence of fluid responsiveness and tissue hypoperfusion. Concerning the controlled trials that compared different solutions, one study failed to show benefits of hypertonic over isotonic hydroxyethyl starch, while another found improved microcirculation after early goal-directed therapy with hydroxyethyl starch than with 0.9% NaCl. Since both studies included a small sample, the results are inconclusive. The third trial, which recruited 100 septic patients, concluded that albumin was superior to balanced solution; however, this conclusion is flawed by methodological problems. Some experimental studies also showed controversial results. Some studies which suggested benefits of albumin, hydroxyethyl starch and high viscosity solutions could not be properly replicated in patients. Superiority of balanced crystalloids over 0.9% NaCl was not consistently demonstrated in basic research. Moreover, some clinical and experimental studies have severe limitations, such as the use of inadequate analysis of microcirculation and compression artifacts in the video acquisition.

Conclusions: Fluid administration probably improves sublingual microcirculation when tissue perfusion is altered and cardiac output increases. The superiority of any solution for this purpose has not been clearly demonstrated. High-quality studies are needed to clarify the effects of different solutions on sublingual microcirculation.

Background: Pulmonary fibrotic changes (FC) following COVID-19-related ARDS represent a significant concern due to the potential respiratory complications. The identification of early predictive factors for FC and the development of predictive tools are needed to optimize patient management and outcomes.

Methods: This observational prospective multicentre study is a substudy of the RECOVIDS study and included 32 centres in France and Belgium. COVID-19 ARDS survivors were included if they met the Berlin ARDS criteria or if they received high flow oxygen therapy (flow ≥ 50 L/min and FiO₂ ≥ 50%). Exclusion criteria were non-attendance at follow-up 6 ± 1 months after ICU discharge, lack of baseline or follow-up chest CT, and history of interstitial lung disease. The primary endpoint was presence of FC at follow-up CT. The secondary outcome was to identify predominant radiological patterns.

Results: Among 555 patients included in the RECOVIDS study, 440 were analysed, of whom 162 (36.8%) had FC at follow-up. Predictive factors for FC included older age, body mass index < 30, Charlson comorbidity index ≥ 1, invasive mechanical ventilation, early signs of FC, and greater lung involvement on baseline CT. The nomogram for predicting pulmonary FC yielded an AUC of 80.6% (95%CI (76.4-84.8)). Late organizing pneumonia was the most common pattern overall and 30 (18.5%) of the 162 patients with FC presented mainly anterior fibrosis compatible with post ventilatory changes.

Conclusion: In this large cohort of COVID-19 ARDS survivors, 36.8% exhibited FC at 6 months post-ICU discharge. The key predictors identified here could guide therapeutic and follow-up strategies.

Background: Impaired peripheral perfusion is linked to poor outcomes in critically ill patients, but the relationships among common bedside assessment tools remain unclear. This study aimed to evaluate whether these parameters provide overlapping or complementary prognostic information across ICU subgroups.

Methods: Adult ICU patients with an expected stay ≥ 3 days were included. On day 1, six peripheral perfusion parameters were simultaneously measured: Peripheral Perfusion Index (PPI), Mottling Score (MS), Capillary Refill Time (CRT), central-to-peripheral temperature gradient (ΔT), Skin Blood Flow at basal temperature (SBF_BT), and forearm tissue oxygenation (rSO₂). The primary outcome was correlation between parameters; secondary outcomes included subgroup consistency and associations with ICU mortality.

Results: Fifty-five patients were included (median age 64; 65.5% male). Circulatory shock (36.4%) was the leading admission cause, followed by acute brain injury (ABI; 29.1%) and acute respiratory failure (ARF; 25.4%). Strong correlations were found between PPI, CRT, SBF_BT, and ΔT, while rSO₂ showed no significant associations. Correlations were strongest in circulatory shock, weaker in ABI and ARF subgroups. CRT had the highest predictive value for ICU mortality (AUC = 0.75, p = 0.007), followed by MS (AUC = 0.72), SBF_BT, and PPI. ΔT showed limited performance, and rSO₂ was the weakest predictor.

Conclusions: Most bedside peripheral perfusion parameters were strongly interrelated, particularly PPI, SBF_BT, and ΔT. In contrast, rSO₂ appeared poorly correlated and less predictive. CRT emerged as the most reliable marker of ICU mortality.

Background: Mortality of immunocompromised patients is particularly high in intensive care units (ICUs) and mainly depends on severity at admission. Moreover, mortality is also high during the months following ICU discharge. The reasons for these poor outcomes after ICU discharge have not been adequately studied.  RESEARCH QUESTION: We hypothesized that the factors associated with poor outcomes after ICU discharge of immunocompromised patients would be different from those associated with in-ICU mortality.

Study design and methods: This is a post-hoc analysis of a multicenter clinical trial comparing two noninvasive oxygenation strategies in immunocompromised patients admitted to ICU for acute hypoxemic respiratory failure. Multivariable analyses were performed to determine early factors (i.e within 6 h of admission) associated with in-ICU mortality, as well as factors associated with poor functional outcomes (i.e death or survival with poor performance status) at 6 months, only in ICU survivors.

Results: Among the 299 patients analyzed, the mortality rate was 31% (94 patients) in the ICU and 49% at 6 months (146 patients). Solid cancer (adjusted odds ratio 2.92 [95% confidence interval, 1.22-7.28]), severity SOFA score at admission (aOR 1.29 [1.14-1.48]), the extent of pulmonary infiltrates on chest X-ray (aOR 1.57 [1.17-2.15]) and increased discomfort one hour after initiation of noninvasive respiratory support (aOR 2.08 [1.12-3.85]) were independently associated with in-ICU mortality. Out of the 202 ICU survivors whose performance status was reported, solid cancer (aOR 3.03 [1.33-9.09]) and poor performance status before ICU admission (aOR 2.43 [1.03-5.88]) were both associated with poor outcome at 6 months, independently from the decision to forgo life-sustaining therapies (aOR 5.88 [2.17-20.00]).

Interpretation: Whereas in-ICU mortality of immunocompromised patients with acute respiratory failure was mainly driven by severity, poor outcomes at 6 months were mainly driven by performance status before ICU admission. Solid cancer was independently associated with both poor short as well as longer-term outcomes. Trial registration Clinical trial registration: NCT04227639.

Context: Real-time PCR (rt-PCR) using cycle threshold (Ct) is a semi-quantitative way to assess DNA amounts, which has become broadly used to diagnose Pneumocystis jirovecii pneumonia (PJP) in non-HIV immunocompromised patients. We aimed to describe the non-HIV immunocompromised patients hospitalized in intensive care unit (ICU) for acute respiratory failure (ARF) and to evaluate the relevance of PJP rt-PCR Ct value in diagnosing PJP. Moreover, the added value of serum 1.3 ß-D-glucan (BDG) assay in this population was also assessed.

Methods: All non-HIV immunocompromised ICU patients with ARF with at least one rt-PCR performed in broncho-alveolar lavage (BAL) from 2013 to 2023 were retrospectively included. Patients with a positive RT-PCR were classified by reviewers aware of the PCR result, but blinded to Ct values, into confirmed, uncertain, or ruled-out PJP groups based on clinical presentation, imaging findings, organism identification, laboratory results, presence of alternative diagnoses, and the resolution of acute respiratory failure with or without appropriate PJP treatment. PJ rt-PCR Ct and BDG assays of each group were compared. Uncertain diagnoses were excluded from the primary analysis and successively considered as confirmed PJP or ruled-out PJP in a secondary analysis. Using the area under the curve (AUC) of the receiver operating characteristics curves, the best threshold of Ct value was defined.

Results: Out of the 481 non-HIV immunocompromised patients who underwent a PJ rt-PCR in BAL, 59 (12%) had a positive test. The results confirmed PJP for 23/59 (39%), ruled it out for 27/59 (46%), while it remained uncertain for 9/59 (15%). Rt-PCR sensitivity and specificity were respectively 100% (95% CI = [85.7-100%]) and 94% (95% CI = [91.4-95.8%]). Median Ct and BDG levels differed significantly between the confirmed, uncertain, and ruled-out groups at 25, 31, and 34 cycles; and 523, 78, and 32 pg/ml, respectively. The primary analysis identified the best Ct to categorize patients at 30, with an AUC of 0.931 (95% CI [0.850-1.0]), a sensitivity of 86% and a specificity of 89%.

Conclusions: Semi-quantitative PJ PCR was accurate in diagnosing PJP in non-HIV ICU patients with acute respiratory failure (ARF), and a Ct at low cycle values was more frequent in confirmed PJP than in colonization. The optimal Ct threshold was 30. The BDG assay was especially valuable when high levels were reached.