Shepard LN, DeVivo A, Abella BS
… +1 more, Morgan RW
Crit Care Clin
· 2026 Jan · PMID 41260707
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Current cardiopulmonary resuscitation (CPR) guidelines rely on standardized metrics, yet substantial evidence reveals significant variability in patients' physiologic responses. Physiology-directed CPR represents an inno...Current cardiopulmonary resuscitation (CPR) guidelines rely on standardized metrics, yet substantial evidence reveals significant variability in patients' physiologic responses. Physiology-directed CPR represents an innovative approach aimed at improving cardiac arrest outcomes by tailoring resuscitation efforts to patient-specific physiologic responses rather than rescuer performance alone. Data indicate that intra-arrest markers including arterial blood pressure, end-tidal carbon dioxide, and cerebral oximetry are associated with cardiac arrest outcomes and can potentially be targeted during CPR. This article explores the underlying physiology, supporting data, advantages, and limitations of these monitoring strategies, highlighting the promise of a shift toward physiology-directed, precision-based resuscitation practices.
Crit Care Clin
· 2025 Oct · PMID 41101842
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The evolution of sedation in intensive care is complex but can help guide expectations of what the future might bring. Sedation and analgesia together with delirium prevention and treatment have evolved in lock step. Lon...The evolution of sedation in intensive care is complex but can help guide expectations of what the future might bring. Sedation and analgesia together with delirium prevention and treatment have evolved in lock step. Longer-acting drugs like lorazepam have been replaced with shorter-acting agents like propofol. Dexmedetomidine has become a frequent treatment of delirium. Longer-acting opioids remain dominant. The target has become lighter sedation rather than deep sedation, but monitoring of sedation and pain remains imperfect and subjective. The future will likely bring the introduction of ultra-short-acting analgesic agents and the greater use of adjunctive dexmedetomidine.
Carini FC, Lillo E, Vecchio G
… +2 more, Giannasi S, Castro DM
Crit Care Clin
· 2025 Oct · PMID 41101841
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This article provides a comprehensive guide for the management of sedation of patients with cardiovascular diseases requiring critical care. It emphasizes pain, agitation, and delirium management, with a focus on the ABC...This article provides a comprehensive guide for the management of sedation of patients with cardiovascular diseases requiring critical care. It emphasizes pain, agitation, and delirium management, with a focus on the ABCDEF bundle and both subjective and objective assessment tools. Key topics include pain and sedation monitoring, Enhanced Recovery After Surgery protocols, early extubation, and analgesics and sedatives pharmacology. Special considerations for patients undergoing cardiopulmonary bypass, mechanical circulatory support, or those with pulmonary hypertension are discussed. By integrating these practices, clinicians can enhance recovery, prevent postintensive care syndrome, and improve patient outcomes in cardiovascular intensive care settings.
Crit Care Clin
· 2025 Oct · PMID 41101840
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Using the PubMed database, the authors conducted a literature search that included the following terms: "sedation OR hypnotics", AND "critically ill OR critical care OR intensive care" AND "adult", AND "traumatic brain i...Using the PubMed database, the authors conducted a literature search that included the following terms: "sedation OR hypnotics", AND "critically ill OR critical care OR intensive care" AND "adult", AND "traumatic brain injury OR acute brain injury OR cardiac arrest". Reference lists were checked for additional material. Included were relevant articles published in English until November 2024 pertinent to adults with acute brain injury, including cardiac arrest.
Crit Care Clin
· 2025 Oct · PMID 41101839
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Polytrauma represents a distinct clinical challenge, characterized by multiple simultaneous traumatic injuries and requiring a coordinated, multidisciplinary approach for effective management. This review outlines a phas...Polytrauma represents a distinct clinical challenge, characterized by multiple simultaneous traumatic injuries and requiring a coordinated, multidisciplinary approach for effective management. This review outlines a phase-specific, evidence-based approach to optimizing sedation and analgesia in polytrauma patients, excluding those with brain injury. Validated assessment tools such as the Richmond Agitation-Sedation Scale and the critical care pain observation tool are emphasized, alongside adjunctive methods like bispectral index monitoring in select cases. A structured, trauma-informed approach is critical to optimize recovery, reduce complications, and enhance quality of life.
Crit Care Clin
· 2025 Oct · PMID 41101838
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Acute respiratory distress syndrome (ARDS) is a critical condition affecting 10% to -15% of ICU patients, with mortality rates varying according to severity. Mechanical ventilation is essential but requires strategies to...Acute respiratory distress syndrome (ARDS) is a critical condition affecting 10% to -15% of ICU patients, with mortality rates varying according to severity. Mechanical ventilation is essential but requires strategies to prevent ventilator-induced lung injury (VILI) and comfort the patient. Sedation and analgesia improve tolerance to ventilation, but excessive deep sedation can be harmful. Guidelines recommend light sedation with daily interruptions or dose titration, though severe ARDS cases may require neuromuscular blockade and, consequently, deep sedation. Specific ventilation and sedation strategies, to modulate respiratory drive and allow spontaneous breathing without vigorous efforts, are necessary to optimize care and improve survival in patients with severe ARDS.
Marra A, Smith RJ, Pandharipande PP
… +1 more, Hayhurst CJ
Crit Care Clin
· 2025 Oct · PMID 41101837
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Sedation is required to tolerate mechanical ventilation in patients with sepsis and septic shock. Caution should be used with dosing strategies in this patient population. It is recommended that an analgesia-first approa...Sedation is required to tolerate mechanical ventilation in patients with sepsis and septic shock. Caution should be used with dosing strategies in this patient population. It is recommended that an analgesia-first approach be used, and sedatives added as needed. Propofol and dexmedetomidine are the preferred agents, as recommended by the Society for Critical Care Medicine's Assess, Prevent, and Manage Pain, Both Spontaneous Awakening Trials and Spontaneous Breathing Trials, Choice of analgesia and sedation, Delirium: Assess, Prevent, and Manage, Early mobility and Exercise, and Family engagement and empowerment bundle. Further research is needed for best practices in patients requiring higher-dose sedatives.
Crit Care Clin
· 2025 Oct · PMID 41101836
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Noninvasive positive pressure ventilation (NIV) is an important tool for treating the critically ill. Unfortunately, NIV intolerance is a potential reason why patients will fail NIV and have to be intubated and invasivel...Noninvasive positive pressure ventilation (NIV) is an important tool for treating the critically ill. Unfortunately, NIV intolerance is a potential reason why patients will fail NIV and have to be intubated and invasively mechanically ventilated. Providing sedation is a possible solution to improve intolerance. While many sedative/analgesic options exist such as dexmedetomidine, ketamine, opioids, benzodiazepines, or propofol, little research is available to guide these choices. Because of the paucity of data, there are no clinical practice guideline recommendations to assist the clinician.
Crit Care Clin
· 2025 Oct · PMID 41101835
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The global population is aging with a concurrent increase in the proportion of intensive care unit (ICU) patients 65 years of age or greater. These older adults often present with geriatric syndromes that increase their...The global population is aging with a concurrent increase in the proportion of intensive care unit (ICU) patients 65 years of age or greater. These older adults often present with geriatric syndromes that increase their vulnerability to critical illness and predispose them to poor short- and long-term outcomes. Sedation exposure in these patients is often necessary but carries risk. In this review, the authors summarize geriatric principles pertinent to an ICU clinician. Then, sedation choices, strategies, and adjuncts that decrease exposure and potentially improve short- and long-term outcomes are discussed.
Crit Care Clin
· 2025 Oct · PMID 41101834
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Inhaled anesthetics are gaining recognition as alternatives to intravenous sedatives in the intensive care unit. As sedatives for mechanically ventilated patients, they offer rapid onset, bronchodilation, and minimal sys...Inhaled anesthetics are gaining recognition as alternatives to intravenous sedatives in the intensive care unit. As sedatives for mechanically ventilated patients, they offer rapid onset, bronchodilation, and minimal systemic metabolism. Historically, volatile anesthetics were mostly used in refractory status asthmaticus or epilepticus using an anesthesia machine with a vaporizer. Sedation with the volatile agents can provide effective sedation and potentially promote faster extubation for mechanically ventilated patients. Although they offer unique advantages in this population, risks such as hypotension and elevated intracranial pressure may limit their use in certain cases.
Crit Care Clin
· 2025 Oct · PMID 41101833
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Optimal depth of sedation in critically ill patients is essential to prevent complications related to oversedation or undersedation. Current best practices aim for a calm, responsive state unless deep sedation is clinica...Optimal depth of sedation in critically ill patients is essential to prevent complications related to oversedation or undersedation. Current best practices aim for a calm, responsive state unless deep sedation is clinically indicated. Tools like the Richmond Agitation-Sedation Scale and others provide structured frameworks for assessing sedation and agitation levels. RASS is the most widely used due to its simplicity, reliability, and broad validation. Combining sedation scoring systems with feedback devices such as the Bispectral Index offers a multimodal strategy for sedation management. This dual approach is considered as best practice, balancing the strengths of behavioral scoring with objective monitoring.
Amer M, AlMubayedh HO, Bolesta S
… +1 more, Gélinas C
Crit Care Clin
· 2025 Oct · PMID 41101832
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This article aims to discuss the importance of the analgesia-first strategy for pain management in critically ill adults. Pain monitoring, nonpharmacologic and pharmacologic treatments as part of a multimodal analgesia a...This article aims to discuss the importance of the analgesia-first strategy for pain management in critically ill adults. Pain monitoring, nonpharmacologic and pharmacologic treatments as part of a multimodal analgesia approach, and strategies for optimizing analgesia in specific populations are addressed. Practical recommendations and future research directions are also highlighted.
Crit Care Clin
· 2025 Oct · PMID 41101831
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Antipsychotics are an attractive option for adjunctive sedation in critically ill adults given their sedating effects, short duration of action, lack of effect on respiratory drive, and multiple routes of administration...Antipsychotics are an attractive option for adjunctive sedation in critically ill adults given their sedating effects, short duration of action, lack of effect on respiratory drive, and multiple routes of administration but high-quality evidence from RCTs is not yet available to guide the use of these agents as adjunct sedatives in the intensive care unit. The purpose of this article is to explore the role of antipsychotics as adjunctive sedatives in mechanically ventilated adults receiving continuous sedation.
Crit Care Clin
· 2025 Oct · PMID 41101830
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The alpha agonists clonidine and dexmedetomidine differ from gamma-aminobutyric acid agonists in mechanism for achieving sedation, analgesia, and promoting sleep. They may reduce delirium prevalence and duration. α-2 ago...The alpha agonists clonidine and dexmedetomidine differ from gamma-aminobutyric acid agonists in mechanism for achieving sedation, analgesia, and promoting sleep. They may reduce delirium prevalence and duration. α-2 agonists act centrally, spinally, and peripherally to modulate multiple sedative, analgesic, and inflammatory pathways. They reduce sympathetic activity, which mediates the most frequent side-effects of bradycardia and hypotension. Dexmedetomidine has 8-times higher α-2:α-1 receptor affinity than clonidine, and greater evidence for effectiveness. The pharmacokinetic profile is predictable, whereas clonidine elimination is unpredictable in critical illness. Current costs are comparable. The risk/benefit balance for both agents remains uncertain and is likely patient specific.
Badie S, Mahmud M, Williamson D
… +1 more, Burry L
Crit Care Clin
· 2025 Oct · PMID 41101829
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This article provides a focused review of 4 sedatives commonly administered to critically ill patients worldwide as continuous infusions-propofol, benzodiazepines, ketamine, and barbiturates. The article covers key pharm...This article provides a focused review of 4 sedatives commonly administered to critically ill patients worldwide as continuous infusions-propofol, benzodiazepines, ketamine, and barbiturates. The article covers key pharmacokinetic-dynamic parameters, mechanisms of action, and adverse effects, highlighting critical issues that often limit therapy.
This article aims to provide clinicians with a comprehensive overview of the diverse applications and critical importance of point-of-care ultrasound in perioperative care. By delving into the practicalities and benefits...This article aims to provide clinicians with a comprehensive overview of the diverse applications and critical importance of point-of-care ultrasound in perioperative care. By delving into the practicalities and benefits of bedside ultrasound, we seek to illuminate how this technology can elevate the standards of patient care, ensuring improved outcomes through enhanced diagnostic accuracy and timely interventions. This article focuses on the assessment of the airway, gastric content, resuscitation, and pulmonary pathology.
This article explores the transformative potential of artificial intelligence (AI) in critical care ultrasound AI technologies, notably deep learning and convolutional neural networks, now assisting in image acquisition,...This article explores the transformative potential of artificial intelligence (AI) in critical care ultrasound AI technologies, notably deep learning and convolutional neural networks, now assisting in image acquisition, interpretation, and quality assessment, streamlining workflow and reducing operator variability. By automating routine tasks, AI enhances diagnostic accuracy and bridges training gaps, potentially democratizing advanced ultrasound techniques. Furthermore, AI's integration into tele-ultrasound systems shows promise in extending expert-level diagnostics to underserved areas, significantly broadening access to quality care. The article highlights the ongoing need for explainable AI systems to gain clinician trust and facilitate broader adoption.
Critical care ultrasound (CCUS) is a tool enabling providers to deliver bedside care to the sickest patients in the hospital. Competency in CCUS involves understanding its indications, acquiring and interpreting images,...Critical care ultrasound (CCUS) is a tool enabling providers to deliver bedside care to the sickest patients in the hospital. Competency in CCUS involves understanding its indications, acquiring and interpreting images, and integrating this information for clinical decision-making. Core examinations include focused transthoracic echo (basic and/or advanced), thoracic ultrasound, abdominal ultrasound, vascular diagnostic, and procedural guidance. Certification, provided by an external professional society or certifying body, and credentialing, conducted internally by an individual provider's health care organization, are both processes designed to ensure competency. This article clearly defines these concepts, reviews relevant literature, and offers guidance on best practices.