Stapleton RD, Kamdar BB, Colantuoni EA
… +16 more, Pandian V, Friedman LA, Bates JHT, Ardren SS, Burns S, Fatima A, Fine JM, Kalva T, Mahmoud MA, Roberts D, Ventrone S, Viana J, McGinnis RS, Pavini MT, Needham DM, FREEDOM Study Team
Crit Care Med
· 2026 May · PMID 42206929
·
Publisher ↗
OBJECTIVES: To evaluate a novel device, developed under a National Institutes of Health Small Business Technology Transfer program grant, designed as an alternative to traditional wrist restraints. DESIGN: Within-patient...OBJECTIVES: To evaluate a novel device, developed under a National Institutes of Health Small Business Technology Transfer program grant, designed as an alternative to traditional wrist restraints. DESIGN: Within-patient crossover phase II randomized trial. SETTING: Four U.S. academic medical centers. PATIENTS: ICU patients (n = 54) who were verbally responsive with a provider order for wrist restraints and expected stay greater than or equal to 2 days. INTERVENTIONS: Alternating use of novel device vs. traditional restraint during 4-hour assessment periods over 2 days (four assessment periods), with randomization of initial allocation to novel device vs. restraint. MEASUREMENTS AND MAIN RESULTS: Upper extremity activity (measured via wrist actigraphy) was the primary outcome, with safety, sedation, delirium, satisfaction (via Quebec User Evaluation of Satisfaction with Assistive Technology [QUEST] survey), and qualitative analyses of survey data as secondary outcomes. Analysis of actigraphy data demonstrated similar mean activity counts per 4-hour session for the novel device vs. traditional restraints, with a range of mean activity across the four sessions of 2930-4395 vs. 3898-4910, respectively, with relative mean total activity count per session of 0.93 (95% CI, 0.76-1.13; p = 0.45). Across 98 sessions using the novel device, 2 (2%) potential safety events were reported. No statistically significant differences were observed in sedation/agitation, or delirium status and severity. Of the QUEST satisfaction surveys completed by patient/family (n = 25) and clinicians (n = 79), 58% and 51%, respectively, indicated high satisfaction with qualitative analyses demonstrating four positive and six constructive themes. CONCLUSIONS: No differences in upper extremity activity, delirium, sedation, or agitation were demonstrated between the novel device and traditional wrist restraints. The novel device had overall moderate patient/family and clinician satisfaction, and qualitative analyses provide important insights for advancing the development of novel restraint alternative devices.
Riccardi J, Robles AJ, Ross JT
… +5 more, Lewis C, Bellini AR, Mell M, Holcomb JB, Callcut RA
Crit Care Med
· 2026 May · PMID 42206924
·
Publisher ↗
OBJECTIVES: Acute traumatic coagulopathy is known to occur early following severe injury. However, the role and impact of both pro- and anti-inflammatory cytokines are unknown. We aimed to investigate the inflammatory (p...OBJECTIVES: Acute traumatic coagulopathy is known to occur early following severe injury. However, the role and impact of both pro- and anti-inflammatory cytokines are unknown. We aimed to investigate the inflammatory (pro- and anti-inflammatory cytokines) and coagulation pathways following injury and their relation to 30-day mortality. DESIGN: Patients included in this analysis had complete data available for a panel of 48 coagulation and inflammatory biomarkers obtained from initial emergency department blood draws. Principal component analysis (PCA), a dimensionality-reduction machine learning method, was used to identify biomarker phenotypes present. Principal components with variance (eigenvalues) greater than 1 were selected for inclusion in the analysis. Least Absolute Shrinkage and Selection Operator regression was performed to identify independent predictors of 30-day mortality. The critical administration threshold (CAT, > 3 units of RBCs in 1 hr) was used to quantify bleeding. SETTING: This is a secondary analysis of the Pragmatic Randomized Optimal Platelet and Plasma Ratio (PROPPR) study. PATIENTS: The PROPPR study was a pragmatic, phase 3, multisite, randomized clinical trial that included 680 severely injured patients at 12 level 1 trauma centers. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Inflammatory and coagulation marker phenotypes were associated with 30-day mortality. Among 286 patients included, 30-day mortality was 24.4% (n = 70). PCA found 14 phenotypes that collectively explained 83% of pathophysiologic variability. The top six principal components contributing to the early pathophysiology changes were a coagulopathy phenotype, followed by two distinct mixed inflammatory phenotypes, a platelet phenotype representing platelet activation integrins, von Willebrand Factor (vWF), and a thromboelastography phenotype representing clot strength and thrombin generation. Controlling for age, sex, injury mechanism, and bleeding (CAT+), mortality was predominantly driven by the coagulopathy phenotype 1 (p = 0.0002) and mixed inflammatory phenotype 3 (p = 0.0684). CONCLUSIONS: These findings demonstrate that coagulation and inflammation are coactivated early after severe injury and are associated with poor outcomes. The activation of these pathways is both complex and integrated, involving inflammatory cytokines, chemokines, growth factors, coagulation factors, platelet activated integrins, vWF, and thrombin. This study uses the largest comprehensive array of coagulation and inflammatory biomarkers to date and identifies key biologic phenotypes linked to mortality after severe trauma.
Wunsch H, Manoharan V, Hill A
… +15 more, Garland A, Costa DK, Kho ME, Lamontagne F, Murthy S, Stelfox HT, Hancock J, Burry L, Dale C, Fenton M, Misak C, Mohamed A, Fowler R, Burns KEA, Gershengorn HB
Crit Care Med
· 2026 May · PMID 42206918
·
Publisher ↗
OBJECTIVE: To provide national data on intensivist coverage and interprofessional team staffing in Canadian ICUs. DESIGN: Cross-sectional survey. SETTING: All Canadian hospitals identified as potentially having an adult...OBJECTIVE: To provide national data on intensivist coverage and interprofessional team staffing in Canadian ICUs. DESIGN: Cross-sectional survey. SETTING: All Canadian hospitals identified as potentially having an adult ICU. SUBJECTS: ICU nurse/physician leaders. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We contacted ICU nurse/physician leadership by email. The questionnaire included questions about interprofessional ICU staffing, availability and roles. Questionnaires were administered from September 2024 to February 2025; data were cleaned and analyzed February to May 2025. We included responses from 137 unique adult ICUs in 123 hospitals (40.9% of 301 hospitals queried), representing all Canadian provinces and territories with ICUs. ICU size varied (median [interquartile range]: 14 beds [8, 20]); most were for mixed patient populations (123 [89.8%]) and had intensivist coverage (119 [86.9%]). Among units with intensivists, they were onsite 24 hr/d in 28/119 (23.5%), and intensivists had simultaneous responsibilities outside the ICU in 47/119 (39.5%). Physicians-in-training were present on weekdays in 112/137 units (81.8%) and advanced practice providers (APPs) in 32/136 (23.5%). For mechanically ventilated patients, the nurse:patient ratio was most commonly 1:1 (66.7%). Respiratory therapists were available on weekdays in 133/137 (97.1%), clinical pharmacists in 123/136 (90.4%) and physical therapists in 126/134 (94.0%). CONCLUSIONS: Most Canadian adult ICUs were staffed by intensivists with less than 25% having onsite intensivist coverage 24 hr/d. Physicians-in-training were present in the majority of ICUs, whereas APPs were uncommon. Nurses most commonly provided care for one mechanically ventilated patient each shift. These data establish contemporary staffing benchmarks to inform assessment of baseline ICU workforce needs and guide surge planning at local, provincial, and national levels. They also enable international comparisons and provide essential context for interpreting Canadian critical care research.
Levy D, Boutrot L, Petit M
… +15 more, Hekimian G, Charron C, Kikoïne J, Guihaire J, Hammoudi N, Devos P, Téllez A, Luyt CE, Porizka M, Balik M, Vieillard-Baron A, Schmidt M, Combes A, Saura O, Right Ventricle Eyeball Assessment by a Critical Care Team Organization Research (REACTOR) group
Crit Care Med
· 2026 May · PMID 42189003
·
Publisher ↗
OBJECTIVES: Right ventricular (RV) dysfunction frequently contributes to circulatory failure in critical care, making its diagnosis essential. Although visual assessment is commonly used, its reliability remains debated....OBJECTIVES: Right ventricular (RV) dysfunction frequently contributes to circulatory failure in critical care, making its diagnosis essential. Although visual assessment is commonly used, its reliability remains debated. This study evaluated the concordance between visual grading of RV systolic function, size, and interventricular septal motion and standard quantitative echocardiographic parameters. DESIGN: This was a multicenter international prospective study. SETTING: Raters with different levels of echocardiography expertise reviewed transthoracic echocardiography recordings from 115 critically ill patients. PATIENTS: The raters visually assessed RV systolic function (normal, moderate, or severe dysfunction), RV size (dilated/nondilated), and septal motion (paradoxical/nonparadoxical). Quantitative parameters, blinded to raters, included fractional area of change (FAC), tricuspid annular plane systolic excursion (TAPSE), S' wave, and RV-free wall longitudinal strain (RVFWLS), according the most recent (2025) guideline-recommended thresholds for abnormality and severity. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Seventy-three raters from five countries participated. Agreement between visual grading and FAC was strong for experts (κ = 0.73) and intermediates (κ = 0.64), but only moderate for novices (κ = 0.55). Overall visual assessment showed moderate agreement with RVFWLS (κ = 0.45), TAPSE (κ = 0.44), and S' wave (κ = 0.43). Agreement for RV size was moderate using RV basal diameter (κ = 0.43) and RV/left ventricle (LV) area ratio (κ = 0.47), but low for the RV/LV basal diameter ratio (κ = 0.25). Concordance for septal motion was low (κ = 0.28). CONCLUSIONS: Visual assessment of RV function by experienced raters shows satisfactory concordance with guideline-based FAC, supporting its integration into a multiparametric evaluation and structured educational programs.
Cooper HA, Fordyce CB, Herbert BM
… +7 more, Alexander JH, Rao SV, Brooks MM, Bertolet M, Carson JL, Hébert PC, Myocardial Ischemia and Transfusion (MINT) Trial Investigators
Crit Care Med
· 2026 May · PMID 42188994
·
Publisher ↗
OBJECTIVES: Anemia is common in critically ill patients. In prior trials, a restrictive transfusion strategy was at least as effective as, and possibly superior to, a liberal strategy in critically ill adult patients. Ho...OBJECTIVES: Anemia is common in critically ill patients. In prior trials, a restrictive transfusion strategy was at least as effective as, and possibly superior to, a liberal strategy in critically ill adult patients. However, the Transfusion Requirements in Critical Care (TRICC) trial suggested that a restrictive strategy might be harmful in critically ill patients with ischemic heart disease. Our objective was to compare outcomes for restrictive and liberal transfusion strategies in critically ill and noncritically ill patients with acute myocardial infarction (AMI) and anemia. DESIGN: Subgroup analysis of a parallel, two-arm randomized, controlled trial. SETTING: One hundred forty-four sites in the United States, Canada, France, Brazil, New Zealand, and Australia. PATIENTS: Adult patients with AMI and anemia enrolled in the Myocardial Ischemia and Transfusion (MINT) trial. Patients being treated in an ICU at randomization were considered critically ill. INTERVENTIONS: Patients were randomly assigned to a restrictive (transfuse when hemoglobin < 7-8 g/dL) or liberal (transfuse when hemoglobin < 10 g/dL) transfusion strategy. MEASUREMENTS AND MAIN RESULTS: We determined the effect of transfusion strategy on death and the composite of death/myocardial infarction (MI) at 30 days among critically ill and noncritically ill patients. Of 3504 patients enrolled in MINT, 1679 (47.9%) were critically ill. At 30 days, death (11.9% vs. 6.5%) and death/MI (18.9% vs. 12.7%) occurred more frequently in critically ill patients compared with noncritically ill patients. A restrictive, compared with a liberal, transfusion strategy resulted in a nonsignificant increase in the risk of death by 9% (risk ratio [RR], 1.09; 95% CI, 0.77-1.54) and death/MI by 9% (RR, 1.09; 95% CI, 0.85-1.38) in noncritically ill patients and a nonsignificant increase in the risk of death by 24% (RR, 1.24; 95% CI, 0.95-1.61; interaction p = 0.55) and death/MI by 21% (RR, 1.21; 95% CI, 0.99-1.47; interaction p = 0.52) in critically ill patients. CONCLUSIONS: There is no evidence that the overall MINT trial results, which generally favor a liberal transfusion strategy in AMI patients, apply differently to noncritically ill and critically ill patients.
Wilson JG, Grandits GA, Grund B
… +28 more, Mistry SS, Leroux C, Ringor A, Aggarwal NR, Murray DD, Barkauskas CE, Brown SM, Higgs E, Shaw-Saliba K, Rupert A, Kan VL, Beitler JR, Awan O, Sturgill JL, Dawood H, Kalil AC, Kalomenidis I, Duggal A, Sasson SC, Ho MQ, Nguyen HH, Lundgren JD, Ginde AA, Self WH, Lane HC, Matthay MA, Rogers AJ, Strategies and Treatments for Respiratory Infections and Viral Emergencies (STRIVE) Network and Therapeutics for Inpatients with COVID-19 (TICO) Trial Study Group
Crit Care Med
· 2026 May · PMID 42187543
·
Publisher ↗
OBJECTIVES: The COVID-19 pandemic highlighted an urgent need to more efficiently identify patients at highest risk for developing respiratory failure. We investigated whether plasma levels of lung injury biomarkers are a...OBJECTIVES: The COVID-19 pandemic highlighted an urgent need to more efficiently identify patients at highest risk for developing respiratory failure. We investigated whether plasma levels of lung injury biomarkers are associated with progression to respiratory failure among adults hospitalized with COVID-19 pneumonia without respiratory failure at admission. DESIGN: This was a nested case-control study of COVID-19 patients enrolled in the Accelerating COVID-19 Therapeutic Interventions and Vaccines-3 (ACTIV-3)/Therapeutics for Inpatients with COVID-19 (TICO) platform trial who were on less than 20 L/min supplemental oxygen at enrollment. We compared baseline measurements of lung injury biomarkers between participants who progressed to respiratory failure or died by study day 10 (cases) and matched controls who did not progress to respiratory failure or death. Cases and controls were matched 1:1 on age, baseline oxygen requirement, immunomodulator use, and study arm. SETTING: Hospitals enrolling in the ACTIV-3/TICO trials. PATIENTS: Four hundred five cases and 405 matched controls. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Baseline levels of plasma interleukin (IL)-6, IL-8, IL-18, tumor necrosis factor receptor, angiopoietin-2, soluble receptor for advanced glycation end-products (sRAGE), C-reactive protein (CRP), and surfactant protein D (SPD) were compared between cases and controls using matched logistic regression. Forward variable selection was used to identify biomarkers that were independently associated with progression to respiratory failure or death in a multivariate model. All lung injury biomarkers with the exception of SPD were significantly associated with progression to respiratory failure or death, with sRAGE demonstrating the highest odds ratio (OR) for each doubling of biomarker level (OR, 1.85; 95% CI, 1.61-2.12). In multivariate regression analysis, sRAGE, IL-6, and CRP were independently associated with progression, with sRAGE as the biomarker with the strongest association. CONCLUSIONS: Baseline levels of plasma lung injury biomarkers are significantly associated with progression to respiratory failure or death among hospitalized COVID-19 patients without respiratory failure at admission. These findings support the potential utility of measuring lung injury biomarkers in patients hospitalized without respiratory failure and should be tested in more heterogeneous patient groups including non-COVID-19 cohorts.
Chotalia M, Ali M, Chotalia R
… +3 more, Patel JM, Parekh D, Bangash MN
Crit Care Med
· 2026 Jul · PMID 42187539
·
Publisher ↗
OBJECTIVES: To apply unsupervised clustering methods to hemodynamic and transthoracic echocardiography (TTE) parameters to identify cardiovascular subphenotypes in ICU patients with sepsis. To examine subphenotype associ...OBJECTIVES: To apply unsupervised clustering methods to hemodynamic and transthoracic echocardiography (TTE) parameters to identify cardiovascular subphenotypes in ICU patients with sepsis. To examine subphenotype association with mortality and determine how differing hemodynamic management strategies influence these associations. DESIGN: Retrospective, single-center cohort study. SETTING: University Hospital ICU, Birmingham, United Kingdom. PATIENTS: ICU patients that received TTE within 7 days of sepsis onset between April 2016 and December 2019 (derivation cohort) and January 2020 and December 2021 (validation cohort). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Nine hundred ninety-five patients were included in the derivation cohort and 804 patients in the validation cohort. A four-class model best fit both cohorts: class 1 (51% in derivation cohort, 56% in validation cohort; mostly normal left ventricular [LV] and right ventricular [RV] function), class 2 (30% in derivation cohort, 22% in validation cohort; mostly high cardiac index, hyperdynamic LV ejection fraction), class 3 (10% in derivation cohort, 12% in validation cohort, mostly dilated RV with impaired systolic function), and class 4 (9% in derivation cohort, 10% in validation cohort; mostly low cardiac output, with depressed LV ejection fraction). The four subphenotypes differed in their characteristics and outcomes, with 90-day mortality rates of classes 1-4 of 20%, 46%, 47%, and 41% in the derivation cohort and 18%, 45%, 57%, and 58% in the validation cohort, respectively ( p < 0.0001 for both cohorts). Following multivariable logistic regression analysis, classes 2-4 were independently associated with mortality. Three-variable models had high diagnostic accuracy in identifying all subphenotypes in both cohorts. The association with mortality of classes varied according to differing vasoactive agent and fluid administration strategies. CONCLUSIONS: Clustering analysis identified four cardiovascular subphenotypes in sepsis that reflected distinct circulatory failure mechanisms, were identifiable using simple models, and were associated with differing mortality risks and response to hemodynamic therapies. These classes may represent treatable traits to personalize shock management in sepsis.
Barker AK, Nishimura A, Nuppnau M
… +19 more, Buell KG, Lyons PG, Liao WT, Park-Egan B, Schmid BE, Ingraham NE, Chaudhari V, Gao CA, Ortiz AC, Weissman GE, Chhikara K, Rojas JC, Amaral ACKB, Parker WF, Iwashyna TJ, Hager DN, Sjoding MW, Hochberg CH, Common Longitudinal ICU data Format (CLIF) Consortium
Crit Care Med
· 2026 Jul · PMID 42171428
·
Full text
OBJECTIVES: Despite historically limited adoption of prone positioning, a potentially life-saving guideline-recommended intervention for moderate-severe acute respiratory distress syndrome, its use increased for mechanic...OBJECTIVES: Despite historically limited adoption of prone positioning, a potentially life-saving guideline-recommended intervention for moderate-severe acute respiratory distress syndrome, its use increased for mechanically ventilated patients during the COVID-19 pandemic. Whether implementation of this guideline-recommended intervention was sustained is unknown. Thus, we aimed to evaluate peri-pandemic trends in proning use. DESIGN: We conducted a retrospective cohort study of proning use among mechanically ventilated adults compared across pre-pandemic (from January 2018 to February 2020), pandemic (from March 2020 to February 2022), and post-pandemic (from March 2022 to December 2024) periods. SETTING: Thirty-seven North American hospitals. PATIENTS: Mechanically ventilated patients with persistent moderate-to-severe hypoxemia (Pa o2 /F io2 ≤ 150 mm Hg, F io2 ≥ 0.6, and positive end-expiratory pressure ≥ 5 cm H 2 O). INTERVENTIONS: Proning within 12 hours of meeting hypoxemia criteria. MEASUREMENTS AND MAIN RESULTS: Among 5944 proning-eligible patients, 2155 (36.2%) received proning: 11.0% pre-pandemic, 51.9% pandemic, and 25.6% post-pandemic. The adjusted odds ratio (OR) for proning during the pandemic vs. pre-pandemic periods was 7.6 (95% CI, 5.5-10.4), and during the pandemic vs. post-pandemic periods was 2.7 (95% CI, 1.8-3.9). Proning varied widely by hospital and was quantified with median ORs (median change in odds of proning for similar patients admitted at a lower vs. higher proning hospital) of 2.9 (95% credible interval [CrI], 1.9-5.3) pre-pandemic, 1.9 (95% CrI, 1.6-2.3) pandemic, and 2.3 (95% CrI, 1.8-3.3) post-pandemic. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive vs. negative pandemic-period patients had increased proning use (OR, 5.1; 95% CI, 4.1-5.6), as did pandemic-period patients without SARS-CoV-2 compared with pre-pandemic patients (OR, 3.8; 95% CI, 2.7-5.2). The difference in proning use between pandemic SARS-CoV-2 negative and post-pandemic patients was smaller and not significant (OR, 1.3; 95% CI, 0.9-1.8). CONCLUSIONS: In a North American cohort of proning-eligible patients, proning increased during the pandemic and then declined. Interventions that improve and sustain implementation of this guideline-recommended intervention are needed.
Chen JJ, Lee TH, Chang CH
… +3 more, Lai PC, Tu YK, Huang YT
Crit Care Med
· 2026 May · PMID 42171427
·
Publisher ↗
OBJECTIVES: Acute metabolic acidosis is frequent in critical illness and may be managed with volume replacement therapy, sodium bicarbonate, and renal replacement therapy (RRT). BICARICU-1 and BICARICU-2 trials provided...OBJECTIVES: Acute metabolic acidosis is frequent in critical illness and may be managed with volume replacement therapy, sodium bicarbonate, and renal replacement therapy (RRT). BICARICU-1 and BICARICU-2 trials provided new evidence on bicarbonate therapy. We aimed to systematically evaluate the effects of sodium bicarbonate in critically ill patients. DATA SOURCES: We systematically searched PubMed, Embase, Medline, and the Cochrane Library for randomized controlled trials (RCTs) evaluating sodium bicarbonate vs. placebo in critically ill adults with acute metabolic acidosis. STUDY SELECTION: Only RCTs were selected. DATA EXTRACTION: Primary outcome was RRT; secondary outcomes were mortality, ICU length of stay, ventilator-free days, and vasopressor-free days. DATA SYNTHESIS: We performed Hartung-Knapp random-effects meta-analyses and trial sequential analysis (TSA) for primary outcomes. Bayesian random-effects meta-analyses with noninformative and weakly informative priors were used for sensitivity analysis. Four trials enrolling 1,111 patients were included. Sodium bicarbonate showed a nonsignificant trend toward lower mortality (risk ratio [RR], 0.84; 95% CI, 0.55-1.30); TSA indicated that the cumulative sample size remained far below the required information size, and the mortality effect is inconclusive. Sodium bicarbonate significantly reduced RRT use (RR, 0.69; 95% CI, 0.61-0.78), and TSA supported firm evidence of benefit. Bayesian analyses estimated posterior probabilities of any mortality reduction (RR < 1) and reduced RRT use of 90.4% and 94.6%, respectively. Secondary outcomes remained imprecise, with a trend of toward more vasopressor-free days. CONCLUSIONS: In critically ill adults with acute metabolic acidosis, sodium bicarbonate significantly reduces RRT requirement, with Bayesian analyses suggesting a possibility of mortality benefit, although current evidence remains inconclusive. Larger RCTs or high-quality real-world studies are needed to confirm efficacy of sodium bicarbonate for mortality.
Crit Care Med
· 2026 May · PMID 42171421
·
Publisher ↗
BACKGROUND: After loss, prolonged grief disorder (PGD), posttraumatic stress disorder (PTSD), depression, and anxiety often co-occur, intensifying distress. Correlates of these patterns remain understudied, as most work...BACKGROUND: After loss, prolonged grief disorder (PGD), posttraumatic stress disorder (PTSD), depression, and anxiety often co-occur, intensifying distress. Correlates of these patterns remain understudied, as most work omits anxiety, uses cross-sectional designs, or focuses on fixed factors. Modifiable ICU end-of-life care factors are largely overlooked despite global calls for improvement. OBJECTIVES: To examine factors associated with states of PGD, PTSD, depression, and anxiety, emphasizing modifiable ICU end-of-life care over 2 bereavement years. DESIGN: Prospective cohort study. SETTING: Two Taiwanese medical ICUs. SUBJECTS: Two hundred ninety-one family members. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Multinomial logistic regression examined factors associated with four symptom states: resilient (reference), subthreshold PGD-depression, PGD-dominant, and co-occurring PGD, PTSD, depression, and anxiety states. Factors spanned intrapersonal, interpersonal (perceived social support), and contextual (bereavement-related and death-circumstance) domains. Higher-burden states were associated with lower education, financial hardship, mixed perceived social support, spousal loss, death of a female-cancer patient, shorter time since death, receipt of palliative care, and suboptimal end-of-life indicators, including absence of social worker involvement or a do-not-resuscitate order, family presence at death, and less than high perceived quality of dying and death (QODD). Do-not-resuscitate orders and social worker involvement were linked to lower odds of the co-occurring PGD, PTSD, depression, and anxiety state, while palliative care and family presence at death were associated with increased odds. Compared with high QODD, moderate QODD was associated with all higher-burden states, while poor-to-uncertain or worst QODD was associated with the subthreshold PGD-depression and co-occurring PGD, PTSD, depression, and anxiety states. CONCLUSIONS: Higher-burden symptom states reflect both unmodifiable vulnerabilities and potentially modifiable peri- and post-loss factors, including interpersonal and death-related circumstances. These findings suggest that aspects of end-of-life care-such as QODD, family support (especially when encouraging presence at patient death), timely do-not-resuscitate orders, social worker involvement, and early palliative care referral-may be relevant targets for future interventions to mitigate concurrent emotional distress in bereaved families.
Hellenthal KEM, Porschen C, Zarbock A
… +6 more, Ertmer C, Lanckohr C, Rohrmann A, von Groote T, Schaumburg F, Lange M
Crit Care Med
· 2026 May · PMID 42171413
·
Publisher ↗
OBJECTIVES: Blood cultures are essential for guiding antimicrobial therapy, but contamination remains a major challenge, particularly when samples are drawn from central venous catheters (CVCs). Blood cultures obtained f...OBJECTIVES: Blood cultures are essential for guiding antimicrobial therapy, but contamination remains a major challenge, particularly when samples are drawn from central venous catheters (CVCs). Blood cultures obtained from CVCs, even when newly inserted, show higher contamination rates than those from peripheral venipuncture, likely due to translocation of skin bacteria during skin dilation and catheter insertion. In critically ill patients with suspected infection or difficult peripheral venous access, CVC insertion often coincides with the indication for blood culture sampling. We hypothesized that obtaining blood cultures directly from the initial central venous puncture before CVC insertion could reduce contamination without impairing true pathogen detection. DESIGN: Retrospective paired comparison study of blood culture sets obtained during CVC insertion: one sample from the initial puncture before, and one from the CVC wire hub after insertion. Microbiological isolates were categorized as contaminants or true pathogens and compared within corresponding sampling pairs. SETTING: Five surgical ICUs of a tertiary care university hospital. PATIENTS: Two hundred twenty-eight critically ill patients requiring CVC placement (from November 2024 to July 2025). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Initial central venous sampling was associated with lower contamination rates than catheter wire hub sampling (3.5% vs. 14.1%), corresponding to an absolute risk difference of -10.6 percentage points (95% CI, -25.6% to -5.4%) and a relative risk of 0.25 (95% CI, 0.12-0.53). The number of procedures with the initial puncture technique required to prevent one contamination was 10 (95% CI, 6-18), and the odds of contamination were significantly lower with initial central venous sampling (odds ratio, 0.22; 95% CI, 0.10-0.49; p < 0.001). Contaminants were mostly coagulase-negative staphylococci, Propionibacterium species, and Corynebacterium species. Detection of true pathogens, including Escherichia coli, Pseudomonas aeruginosa, Klebsiella species, and Staphylococcus aureus, was comparable between techniques. CONCLUSIONS: Initial central venous blood culture sampling before CVC insertion is a simple approach that does not generate additional costs and may reduce contamination while preserving accurate pathogen detection, thereby potentially improving diagnostic certainty and supporting antimicrobial stewardship.
Ma S, Pan Y, He J
… +9 more, Xie H, Cen Z, Liu X, Cai J, Huang B, Wang H, Du Z, Hou X, Liu Z
Crit Care Med
· 2026 May · PMID 42171409
·
Publisher ↗
OBJECTIVES: Patients with acute respiratory distress syndrome (ARDS) undergoing venovenous extracorporeal membrane oxygenation (ECMO) may experience severe cardiogenic shock, necessitating ECMO mode "escalation" for card...OBJECTIVES: Patients with acute respiratory distress syndrome (ARDS) undergoing venovenous extracorporeal membrane oxygenation (ECMO) may experience severe cardiogenic shock, necessitating ECMO mode "escalation" for cardiopulmonary co-support. There is a paucity of data regarding the prevalence, risk factors, and mortality of venovenous ECMO escalation. We aimed to conduct a large study to address this issue. DESIGN: A multicenter cohort study. SETTING: The analysis was conducted based on data from the Chinese Society of Extracorporeal Life Support registry, a nationwide voluntary platform capturing clinical information of patients receiving ECMO support. Data were collected from 112 centers across China between January 2017 and December 2023. PATIENTS: Eligible participants included adult patients with ARDS receiving venovenous ECMO, excluding pregnant patients and those with missing data on escalation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was in-hospital mortality. Of the 3333 patients on venovenous ECMO, 157 (4.7%) underwent escalation to venoarterial ECMO (n = 41), veno-arterial-venous (VAV) ECMO (n = 68), and veno-veno-arterial (VVA) ECMO (n = 48). Several characteristics, including hospital's annual venovenous ECMO volume (hospitals > 15 cases per year vs. those < 6 cases per year; odds ratio [OR], 0.596; 95% CI, 0.382-0.930), were associated with the occurrence of escalation. The overall in-hospital mortality was 47.9%. Both escalation and lower hospital's venovenous ECMO volume were independently associated with an increased mortality. Compared with patients escalated to VVA ECMO, those escalated to venoarterial ECMO had a significantly higher survival rate (OR, 3.444; 95% CI, 1.046-11.342), whereas those escalated to VAV ECMO did not. CONCLUSIONS: In this study, 4.7% of ARDS patients with venovenous ECMO underwent a mode escalation. Escalation was independently associated with higher in-hospital mortality, an association that may be partially confounded by low hospital's venovenous ECMO volume. Among the modes after escalation, venoarterial ECMO was associated with a significantly higher survival rate. These findings require validation by further prospective multicenter studies to guide decision-making for ARDS patients requiring ECMO support.
Crit Care Med
· 2026 May · PMID 42165648
·
Publisher ↗
OBJECTIVE: To determine the transition point to persistent critical illness (PerCI) in Brazilian ICUs and to describe the characteristics, outcomes, and resource utilization of patients who develop PerCI. DESIGN: Multice...OBJECTIVE: To determine the transition point to persistent critical illness (PerCI) in Brazilian ICUs and to describe the characteristics, outcomes, and resource utilization of patients who develop PerCI. DESIGN: Multicenter cohort study. SETTING: Fifty-six adult ICUs participating in the national The Impact of Infections by Antimicrobial-Resistant Microorganisms in Patients Admitted to Adult ICUs in Brazil: Platform of Projects to Support the National Action Plan for the Prevention and Control of Antimicrobial Resistance (IMPACTO-MR) platform across public and private hospitals in Brazil. PATIENTS: Adult patients admitted from September 2019 to December 2023 to the participating ICUs. Patients younger than 18 years, ICU readmissions, and admissions from units with incomplete severity data were excluded. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We derived two predictive models-one based on antecedent characteristics and another on acute illness severity-in a training cohort. We applied both models to a test cohort, and evaluated model discrimination for in-hospital mortality daily for patients who remained in the ICU up to day 28. PerCI was defined as the ICU day at which the predictive discrimination of acute illness severity declined to match or fall below that of antecedent characteristics. A total of 75,475 adult ICU patients admitted between 2019 and 2023 were included. At admission, discrimination was higher for the acute illness model (area under the receiver operating characteristic curve [AUROC] 0.828) than for the antecedents characteristics model (AUROC 0.638). The predictive performance of acute characteristics declined progressively and crossed that of antecedent characteristics on ICU day 15, defining PerCI. Overall, 7960 patients (10.5%) met this definition yet accounted for 44.2% of all ICU bed-days. PerCI patients had ICU mortality of 38.2%, and in-hospital mortality of 51.2%. CONCLUSIONS: In Brazilian ICUs, the transition to PerCI occurs at 15 days, later than that reported in most prior studies. Although only one in ten patients develop PerCI, they use almost half of ICU bed-days. Further research and policy are needed to mitigate potentially modifiable contributors to prolonged critical illness.