Annals of Intensive Care最新文献

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: Controlled donation after circulatory death (cDCD) has been encouraged in many countries for over ten years. This procedure requires close link between intensive care unit (ICU) and organ procurement teams, and relatives. Data on the experiences of these different stakeholders involved in cDCD are scarce.

Objective: To gain insights into the experience of intensive-care teams, organ-procurement teams, and relatives during cDCD.

Methods: For this qualitative study, physician and nurse members of ICU and organ-procurement teams participated in focus groups. Also, relatives of cDCD donors participated in semi-structured telephone interviews a few months after the death. All relatives were included in the ongoing PRODON randomised controlled trial of organ-procurement-team involvement in requesting cDCD from relatives. The staff members worked at hospitals involved in the trial. Interpretative phenomenological analysis was used to assess the focus-group and telephone-interview data. The study was guided by the Standards for Reporting Qualitative Research (SRQR).

Results: We included 23 healthcare professionals and 10 relatives at five hospitals in France. The data show that the cDCD process evolves in three distinct stages in both the professionals and the relatives: uncertainty in the face of a life-threatening disease but persistent hope for survival, shift towards certainty that death is inevitable, and end of life with a request for donation. The professionals sometimes perceived a conflict between a good death and technically successful cDCD. The relatives needed time to come to terms with cDCD and to understand the procedure.

Conclusions: The identification of three stages in the cDCD process can be expected to help intensive-care and organ-procurement teams provide effective support to relatives, define the role of each professional, and strengthen cooperation and communication between the two teams of professionals.

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.

Introduction: Ventilator-associated pneumonia (VAP) and ventilated hospital-acquired pneumonia (vHAP) are major causes of morbidity and mortality in intensive care unit (ICU) patients. The role of viral co-infections in these conditions is an emerging area of interest; however, their impact on clinical outcomes remains poorly understood. This study aimed to assess the effect of viral detection on mortality and other clinical outcomes in patients with bacterial vHAP/VAP.

Materials and methods: We conducted a retrospective analysis of patients diagnosed with bacterial vHAP or VAP in a tertiary ICU between 2020 and 2024. All patients underwent distal respiratory sampling with quantitative culture and multiplex PCR (mPCR) testing for respiratory viruses (Biofire FilmArray Pneumonia Panel). Patients with SARS-CoV-2 infection were excluded. Those with bacterial and viral co-infections were matched 1:1 with patients having bacterial-only vHAP/VAP based on age, sex, SAPS II score, ICU admission cause, and causative bacteria. We compared clinical outcomes, including ICU mortality, 3-month mortality, ICU length of stay, and duration of mechanical ventilation between the two groups.

Results: Eighty patients were included, 40 with bacterial and viral detection and 40 with bacterial-only vHAP/VAP. The median age was 63 years, and 92% of the cohort were male. Common comorbidities included diabetes (25%), heart failure (20%), chronic renal failure (20%), and chronic lung disease (32%). Nineteen percent of patients were immunocompromised. The viral pathogens identified in the co-infection group were rhinovirus/enterovirus 33% (13/40), endemic coronaviruses 30% (12/40), influenza viruses 10% (4/40), parainfluenza viruses 8% (3/10), adenovirus 8% (3/10), metapneumovirus 5% (2/40), and respiratory syncytial virus 5% (2/40). Respiratory viruses were detected in a nasopharyngeal swab in 30% (12/30). The 3-month mortality rate was 36%, ICU mortality was 32%, the median duration of mechanical ventilation was 21 days [IQR 12-31.5], and the median ICU length of stay was 24 days [IQR 13-39.5]. There were no significant differences in these outcomes between the bacterial and viral group and the bacterial-only group.

Conclusions: In this cohort of patients with bacterial vHAP/VAP, the detection of respiratory viruses did not significantly impact ICU mortality, 3-month mortality, or ICU length of stay. These findings may suggest that bacterial infections are the primary determinants of clinical outcomes in vHAP/VAP.

Background: Critical illness myopathy (CIM) increases mortality and causes long-term disabilities. CIM is characterized by reduced muscle excitability, muscle atrophy, weakness, and impaired glucose metabolism. Functional circadian rhythms are important for skeletal muscle homeostasis. Circadian rhythms are often disrupted during critical illness in the Intensive Care Unit (ICU). This analysis investigates whether diurnal temperature rhythms differ in critically ill CIM compared to no-CIM patients.

Methods: This is a secondary analysis of two prospective trials including critically ill patients with CIM (n = 32) or no-CIM (n = 30) based on electrophysiological tests. Diurnal body temperature rhythms were compared between CIM and no-CIM groups in reference to n = 16 participants included in a bed rest study. Cosinor analysis was performed to determine the rhythm parameters and classify into rhythm classes. Aggregated and longitudinal data were compared between groups using non-parametric tests. Rhythm parameters were correlated with muscle atrophy, weakness and insulin sensitivity.

Results: CIM and no-CIM patients had severe multiorgan failure (median SOFA score 12 in both groups, p = 0.39). The temperature rhythm nadir timepoint was shifted in CIM patients (10:43 [09:21, 12:22]) and no-CIM (11:12 [09:43, 13:30]) compared to the healthy bed rest group (5:03 [3:22, 6:36]) p < 0.001. CIM patients showed lower temperature rhythm mesors than no-CIM patients (p = 0.041). The temperature rhythm amplitude was lower in both CIM and no-CIM patients compared to the healthy bed rest group (CIM: 0.3 °C [0.2, 0.4]; no-CIM: 0.2 °C [0.2, 0.3]; healthy bed rest: 0.5 °C [0.2, 0.6]; p < 0.01). Compared to no-CIM patients, CIM patients had higher temperature rhythm amplitudes (p = 0.021) and showed a less pronounced reduction in temperature rhythm amplitudes during ICU stay (p = 0.017). A higher temperature rhythm amplitude correlated negatively with M. vastus lateralis myocyte cross-sectional area.

Conclusions: Heterogeneous phase shifts of diurnal temperature rhythms in CIM and no-CIM groups compared to healthy bed rest volunteers may indicate ICU-related circadian disruption. Suppression of temperature rhythm amplitude during ICU stay could represent an adaptive response to this disruption. Blunted amplitude suppression observed in CIM compared to no-CIM patients might reflect reduced adaptation, potentially contributing to muscle catabolism. This hypothesis-generating analysis underlines the need for mechanistic studies exploring circadian regulation in skeletal muscle during critical illness.

The understanding of the response to stress in critical illness has significantly improved in recent years. These adaptations unfold across acute, subacute, and chronic phases, with an early adaptive catabolic state, marked anabolic resistance, and a later transition toward recovery. The aim of this updated review is to summarize recent advancements focusing on pathophysiological changes in endocrine, immune, gut, and mitochondrial functions and their effects on the metabolic shift in energy production, using glycolysis and the utilization of lactate and ketones as alternative pathways to meet cellular energy demands. Advances in understanding key elements such as energy expenditure and autophagy have expanded our knowledge. Furthermore, there is increased interest in the consequences of an intense and prolonged stress response, which can lead to ICU-acquired weakness (ICU AW) and post-intensive care syndrome. Recent evidence indicates that higher protein strategies generally do not improve survival or functional recovery and may signal harm in patients with renal dysfunction, supporting cautious, phase-appropriate protein dosing rather than routine high targets. New concepts, such as chronic critical illness (CCI) and persistent inflammation, immunosuppression, and catabolism syndrome (PICS), have also emerged to characterize prolonged stress responses. For glycaemic management, intensive control offers no outcome benefit and increases hypoglycaemia risk; moderate targets are preferred. Parallel advancements in monitoring techniques, such as indirect calorimetry and body composition analysis, have improved the assessment of the consequences of the metabolic changes. Metabolomics has offered deeper characterisation of the metabolic response to stress and nutrition, highlighting key metabolic pathways and potential therapeutic targets. Integrating biomarkers and metabolomics to define clinical endotypes may help time the transition from catabolic to anabolic strategies and personalize nutrition and pharmacologic support at the bedside. New therapeutic avenues have emerged or are under investigation, including glycaemic control, nutritional strategies, and some specific interventions targeting key components of the metabolic response. In this context, we present a narrative review of the literature with a focus on the clinical consequences of the pathophysiological and metabolic response to stress, alongside therapeutic implications and future perspectives.