Care of critically ill patients involves large amounts of medication, perhaps more than any other aspect of the healthcare system. This has substantial environmental impacts. This manuscript describes how the environment...Care of critically ill patients involves large amounts of medication, perhaps more than any other aspect of the healthcare system. This has substantial environmental impacts. This manuscript describes how the environmental impacts of medications arise along their lifecycle, how to assess those impacts, and opportunities to reduce medication environmental impact across the critical care and caring continuum. Critical care practitioners and trainees have a long career ahead of them, and should be aware of, reflect, and act to address the planetary impact of medications.
Boyd A, Daenen K, Stoof S
… +18 more, van Willigen HDG, Gommers D, Moeniralam HS, den Uil CA, Juffermans NP, Kant M, Valkenburg AJ, Pillay J, van Gorp E, Schinkel J, van Meenen DMP, Goossen R, Paulus F, Dalm V, Bos LDJ, Endeman H, Huijben JA, PRoVENT- and PRoAcT-COVID Collaborative Group
BACKGROUND: Optimal corticosteroid dosing strategies remain unclear for severe coronavirus disease 2019 (COVID-19) patients admitted to the intensive care unit (ICU). This study compared mortality among patients treated...BACKGROUND: Optimal corticosteroid dosing strategies remain unclear for severe coronavirus disease 2019 (COVID-19) patients admitted to the intensive care unit (ICU). This study compared mortality among patients treated with high-dose versus standard-dose corticosteroids. METHODS: This prospective cohort study included adult patients with COVID-19 ARDS, defined according to Berlin criteria for ARDS, across 22 centers in the Netherlands between March 2020 and January 2021. Mortality hazards were compared between patients receiving high-dose (>6 mg dexamethasone or equivalent) and standard-dose (6 mg dexamethasone or equivalent) corticosteroids using marginal structural models to adjust for time-varying confounding related to initiation of high-dose therapy. Models were constructed using pooled logistic regression with stabilized inverse probability of treatment weights to emulate a per-protocol analysis. RESULTS: Data from 848 patients were analyzed: 378(44.6%) received high-dose and 470 (55.4%) standard-dose corticosteroids. Among those treated with high-dose corticosteroids, 63 (16.7%) started therapy within the first day after ICU admission, and 315(83.3%) started at a median of 9 days(IQR = 4-14) after admission. During a median 28 days of follow-up, 183 patients in the high-dose and 154 in the standard-dose group died [incident rate = 2.12 per 100 person-days, 95% confidence interval (CI) = 1.81-2.43 and 1.41 per 100 person-days, 95%CI = 1.13-1.63, respectively]. In the marginal structural model, high-dose corticosteroids were associated with increased mortality (hazard ratio = 2.45, 95%CI = 1.97-3.05). Risk was higher in male patients or those with late initiation (>1 day) of therapy. CONCLUSION: In patients with COVID-19 ARDS, high-dose corticosteroids were associated with higher mortality during the first 28 days after ICU admission. TRIAL REGISTRATION: ClinicalTrials.govNCT05403359; https://clinicaltrials.gov/ct2/show/NCT05403359.
Georgiou A, Williams K, Bonnici T
… +2 more, Metaxa V, Brummell Z
J Crit Care
· 2026 Jun · PMID 42378819
·
Publisher ↗
PURPOSE: Attitudes toward death and dying are central to intensive care unit (ICU) culture, influencing communication, ethical decision-making, moral distress and professional identity. Yet how these attitudes are measur...PURPOSE: Attitudes toward death and dying are central to intensive care unit (ICU) culture, influencing communication, ethical decision-making, moral distress and professional identity. Yet how these attitudes are measured in adult ICU clinicians, and the robustness of available instruments, remains unclear. We systematically reviewed tools used to assess attitudes toward death and dying in adult ICU staff. METHODS: This systematic review followed PRISMA 2020 guidance and was registered on PROSPERO (CRD420250527706). Medline, PsycINFO, CINAHL and Scopus were searched from January 1980 to December 2024. Original peer-reviewed studies using named quantitative instruments in adult ICU clinicians were included. Study selection was undertaken independently by three reviewers. Measurement properties were appraised using COSMIN criteria, and methodological quality using the Mixed Methods Appraisal Tool (MMAT). Given substantial heterogeneity in constructs and outcomes, findings were synthesised narratively. RESULTS: Fourteen studies reporting eleven primary instruments were included, predominantly involving ICU nurses and cross-sectional designs. Instruments addressed diverse constructs, including caring attitudes, perceived barriers to end-of-life care, ethical sensitivity, organisational values and treatment decision-making. Several tools demonstrated acceptable internal consistency and construct validity. Overall methodological quality was moderate to high, although sampling representativeness and non-response bias were frequently unclear. CONCLUSIONS: Current instruments provide fragmented and conceptually divergent assessments of ICU clinicians' attitudes toward death and dying. Limited cross-cultural validation and poor evidence of responsiveness constrain their usefulness for evaluating interventions or supporting improvement. More coherent, implementation-ready measurement tools are needed to strengthen end-of-life culture in intensive care.
van Gemert J, van den Boogaard M, Hoedemaekers C
… +5 more, van der Hoeven H, Kerckhoffs M, Hinne M, de Keizer N, Zegers M
J Crit Care
· 2026 Jun · PMID 42364273
·
Publisher ↗
PURPOSE: Identifying subgroups of intensive care unit (ICU) patients with high mortality rates can provide directions in policy making about appropriate intensive care medicine. The objective of the study was to identify...PURPOSE: Identifying subgroups of intensive care unit (ICU) patients with high mortality rates can provide directions in policy making about appropriate intensive care medicine. The objective of the study was to identify demographical and clinical characteristics of subgroups of ICU patients with high (≥80%) mortality rates at six months post-ICU admission. METHODS: Data from all Dutch ICU patients admitted between 2013 and 2023 are used. Data are obtained from the Dutch National Intensive Care Evaluation (NICE) registry, including 807,727 ICU admissions from 84 hospitals. A machine learning model was trained on four samples, defined at different stages of the ICU admission with varying amounts of available data. Training was performed on 70% of the hospitals and validation on the other 30% for the years 2013-2022. A temporal validation was performed on data from 2023. RESULTS: Ten high-mortality subgroups were identified. Reduced urine output and a low combined score on the eye & motor components of the Glasgow Coma Scale (GCS) were the most common risk factors defining high-mortality subgroups. External validation showed small deviations in mortality (median absolute deviations -1% and -2%), with one subgroup falling below the 80% mortality threshold. CONCLUSION: Interpretable machine learning can identify ICU patient subgroups with ≥80% 6-month mortality using routinely collected data. These groups are predominantly marked by impaired consciousness and reduced urine output. Future work should integrate these insights into ethical, patient-centered frameworks that support appropriate care.
J Crit Care
· 2026 Jun · PMID 42361768
·
Publisher ↗
BACKGROUND: Balanced crystalloids are widely used as alternatives to 0.9% saline, yet their effects on patient-important outcomes remain uncertain. Cluster-randomized trials provide a pragmatic framework for evaluating f...BACKGROUND: Balanced crystalloids are widely used as alternatives to 0.9% saline, yet their effects on patient-important outcomes remain uncertain. Cluster-randomized trials provide a pragmatic framework for evaluating fluid strategies as implemented in routine clinical practice. We performed a hierarchical Bayesian meta-analysis to estimate the effectiveness of balanced versus saline fluid policies. METHODS: We searched MEDLINE, Embase, and CENTRAL through September 2025 for cluster-randomized and cluster-allocated trials comparing balanced crystalloids with saline across perioperative, emergency, and critical care settings. The primary outcome was all-cause mortality; acute kidney injury (AKI) was secondary. Hierarchical Bayesian random-effects models were fitted using published study-level estimates that accounted for clustering whenever available. RESULTS: Six trials involving 42,223 patients met the inclusion criteria. For mortality, the pooled Bayesian relative effect was 0.92 (95% CrI 0.77-1.18), corresponding to an 83% posterior probability of benefit. For AKI, the pooled Bayesian relative effect was 1.02 (95% CrI 0.86-1.23), corresponding to a 40% posterior probability of benefit. Sensitivity analyses yielded similar findings. CONCLUSIONS: Balanced crystalloid policies were not associated with a clear reduction in mortality or AKI in cluster-randomized evaluations of routine care. Any true effect is likely modest and dependent on exposure and clinical context. The available evidence remains compatible with modest benefit or no meaningful effect and complements patient-level evidence by informing the real-world effectiveness of fluid policies under routine implementation conditions. PROSPERO ID: CRD420251146439.
Jiang X, Zhang L, You J
… +5 more, Ma J, Zhang Y, Hu C, Peng Z, Liu C
J Crit Care
· 2026 Jun · PMID 42341374
·
Publisher ↗
INTRODUCTION: The impact of continuous renal replacement therapy (CRRT) with oXiris hemofilter (oXiris CRRT) on sepsis outcomes remain controversial. We aimed to investigate the association between the oXiris CRRT and su...INTRODUCTION: The impact of continuous renal replacement therapy (CRRT) with oXiris hemofilter (oXiris CRRT) on sepsis outcomes remain controversial. We aimed to investigate the association between the oXiris CRRT and subsequent outcomes in adult patients with septic shock. METHODS: This single-center, retrospective cohort study included adult patients with septic shock, who were admitted to the intensive care unit (ICU) of our tertiary referral hospital between 2019 and 2023, and underwent at least one CRRT session. Patients were categorized into two groups based on the initially hemofilter used (oXiris group vs. M100 group). A 1:1 propensity score matching was performed to compare the primary outcome 28-day vasopressor-free days. RESULTS: Of 465 patients who met all eligibility criteria, 69 cases in the oXiris group were matched with 69 individuals in the M100 group. Compared with the M100 group, the use of oXiris CRRT was associated with longer 28-day vasopressor-free days (24 vs. 19 days, P = 0.04), shorter CRRT duration (72 vs. 117 h, P = 0.03), and a greater reduction in SOFA scores (-2 vs. 1, P = 0.004). However, competing risk analysis indicated no significant between-group difference in the cumulative incidence of vasopressor weaning after accounting for the competing risk of ICU mortality. Furthermore, no significant between-group differences were observed in changes in lactate, PCT, or IL-6 levels, fluid balance, ICU or hospital length of stay (LOS), or short-term mortality. CONCLUSIONS: In this cohort of septic shock patients undergoing CRRT, unadjusted analyses demonstrated potential improvements in hemodynamic stability and organ function following oXiris therapy. Nevertheless, these preliminary signals were not confirmed by competing risk analysis of the primary outcome. Therefore, the clinical impacts of oXiris CRRT observed in the present study must be viewed cautiously, well-designed prospective investigations are warranted to verify its definitive therapeutic value.
Damiani E, Domizi R, Carsetti A
… +8 more, Antolini R, Scorcella C, Casarotta E, Gabbanelli V, Spadoni T, Graciotti L, Adrario E, Donati A
J Crit Care
· 2026 Jun · PMID 42320425
·
Publisher ↗
BACKGROUND: Sepsis-induced coagulopathy (SIC) and microvascular dysfunction are hallmark features of sepsis, yet their relationship remains poorly understood. The primary aim of this study was to investigate whether earl...BACKGROUND: Sepsis-induced coagulopathy (SIC) and microvascular dysfunction are hallmark features of sepsis, yet their relationship remains poorly understood. The primary aim of this study was to investigate whether early microvascular impairment can predict the presence/development of SIC. The secondary objective was to explore the relationship between SIC and the evolution of microvascular perfusion over the first 4 days. METHODS: Prospective observational study on 30 septic patients. Sublingual microcirculation (incident dark-field video-microscopy) was evaluated at day 0 and 4. Standard coagulation tests and thromboelastography were assessed daily. SIC was identified by a SIC score ≥ 4. Plasma syndecan-1 and thrombomodulin levels were measured on day 0. RESULTS: SIC was identified in 20 patients (66.7%) by day 4. On day 0, the microcirculation did not differ between SIC+ and SIC- patients. However those with lower baseline microvascular flow index (MFI <2.92) were more likely to develop SIC (82% vs 46%, p = 0.037). From Day 0 to Day 4, microvascular density (TVD, PVD) decreased in the SIC+ group but increased in the SIC- group (p for interaction <0.05). Baseline Syndecan-1 levels correlated negatively with the variation (Δ) in microvascular density. Correlations were found between Δ-microcirculatory parameters and Δ-coagulation markers, such as Δ-MFI and Δ-INR (r = -0.516, p < 0.05) or Δ-TVD and Δ-platelets (r = 0.442, p < 0.05). CONCLUSIONS: The sublingual microcirculation on day 0 failed to predict the development of SIC. In longitudinal exploratory analysis, SIC was associated with a reduction in microvascular density from day 0 to day 4, although a causal relationship remains to be established.
J Crit Care
· 2026 Jun · PMID 42314519
·
Publisher ↗
Various interventions have been developed to prevent or reduce the risk of Post-Intensive Care Syndrome (PICS) in patients during and after intensive care. This systematic review with narrative synthesis aimed to identif...Various interventions have been developed to prevent or reduce the risk of Post-Intensive Care Syndrome (PICS) in patients during and after intensive care. This systematic review with narrative synthesis aimed to identify, categorize, and synthesize evidence on interventions delivered during the ICU stay or up to 1 year after discharge that may be associated with improved HRQoL and reduced anxiety, depression, and PTSD symptoms in survivors. Following PRISMA guidelines, we searched five databases for interventional studies assessing psychological outcomes in ICU survivors. Quantitative, qualitative, and mixed-methods designs were eligible. Study quality was assessed using RoB 2, ROBINS-I V2, and MMAT. Among 3494 records identified, 39 studies were included. Interventions were grouped into seven categories: physical (n = 8), self-management education strategies (n = 6), evaluative follow-up (n = 2), narrative (n = 10), EMDR (n = 1), ICU simulation with virtual reality (n = 1), and multimodal interventions (n = 11). The evidence remained heterogeneous and methodologically fragile: 14 studies reported improvement in at least one psychological outcome, 23 reported no benefit, and two evaluative interventions were associated with worse outcomes. Narrative and multimodal interventions showed the most consistent signals of benefits, particularly for PTSD, depression, and HRQoL, although evidence often came from studies with methodological limitations. Conversely, interventions focused on assessment, information provision, or unguided self-management did not provide robust evidence of benefit. Future research should prioritize adequately powered, standardized, multimodal programs involving mental health professionals and longer follow-up to better capture delayed psychological outcomes after critical illness trajectories.
J Crit Care
· 2026 Jun · PMID 42314518
·
Publisher ↗
BACKGROUND: Intra-aortic balloon pump (IABP) is a classical mechanical hemodynamic support device. However, the influence of IABP counterpulsation on visceral flow is still undetermined. METHODS: This prospective study i...BACKGROUND: Intra-aortic balloon pump (IABP) is a classical mechanical hemodynamic support device. However, the influence of IABP counterpulsation on visceral flow is still undetermined. METHODS: This prospective study included 33 patients who were treated with the IABP in a single cardiovascular center. Transabdominal echography was used to evaluate blood flow in the visceral branches under IABP support. The aim of this study is to evaluate the influence of the IABP counterpulsation on visceral perfusion and identify the risks of visceral arterial compromise. RESULTS: Visceral perfusion was significantly increased under IABP support in the abdominal aorta (from 15.4 [12.1-30.4] ml/beat to 28.0 [16.0-48.1] ml/beat, P < 0.001), the celiac artery (from 6.4 [3.6-11.4] ml/beat to 9.5 [3.4-16.6] ml/beat, P < 0.001), the superior mesenteric artery (from 6.6 [4.7-9.1] ml/beat to 9.9 [4.3-12.6] ml/beat, P < 0.001), and the left renal artery (from 2.4 [1.8-5.2] ml/beat to 4.3 [3.2-6.8] ml/beat, P = 0.002). Perfusion flow decreased under IABP support in 8 patients (24.2%) at multiple visceral vessels. Between patients with increased and decreased visceral flow, aortic diameter at the celiac trunk level was significantly smaller (22.5 [20.8-24.0] mm vs. 20.5 [19.6-22.3] mm, P = 0.002). CONCLUSION: Visceral flow pattern was a biphasic pulse under IABP support, and total visceral flow was significantly increased. However, a narrow abdominal aorta can be a risk for decreased visceral perfusion.
J Crit Care
· 2026 Jun · PMID 42308610
·
Publisher ↗
ICU admission is often framed as a binary decision between clear indication and non indication. However, daily practice frequently involves intermediate situations characterized by uncertainty regarding the expected bene...ICU admission is often framed as a binary decision between clear indication and non indication. However, daily practice frequently involves intermediate situations characterized by uncertainty regarding the expected benefit of intensive care, referred to as the "gray zone" of ICU admission. This gray zone is expanding due to population ageing, increasing clinical complexity, and technological advances that broaden therapeutic possibilities without ensuring individual relevance. In this context, ICU admission cannot rely solely on prognosis or dichotomous reasoning. The key question is no longer whether to admit, but what level of care is appropriate for a given patient. This article proposes a conceptual and practical framework to address this challenge. We define the gray zone and its main determinants, including clinical, organizational, human, and contextual factors, and describe typical clinical situations in which uncertainty is central. We highlight the limitations of conventional approaches based on prognostic tools or binary ethical concepts. We propose proportionality as a central principle to guide decision-making, allowing graduated and dynamic therapeutic engagement. This approach is operationalized by viewing ICU care as a continuum of interventions, from basic support to advanced organ replacement therapies. Managing the gray zone requires a structured, collegial, and dynamic approach, integrating patient preferences, reassessment over time, and clear communication. Recognizing and structuring the gray zone is essential to modern intensive care practice.
Pichon S, Zebian G, Lacombe C
… +11 more, Mole A, Wemeau L, Ledoult E, Kalioubie AEL, Gaudet A, Robriquet L, Bureau C, Launay D, Levy C, Sobanski V, Jourdain M
J Crit Care
· 2026 Jun · PMID 42288031
·
Publisher ↗
OBJECTIVE: This study aimed to assess the prevalence of immune-related adverse events (irAEs) among patients admitted to the intensive care unit (ICU) while receiving immune checkpoint inhibitor (ICI) therapy, and to des...OBJECTIVE: This study aimed to assess the prevalence of immune-related adverse events (irAEs) among patients admitted to the intensive care unit (ICU) while receiving immune checkpoint inhibitor (ICI) therapy, and to describe their clinical characteristics, management, and outcomes. METHODS: We retrospectively included all patients admitted to the Lille University Hospital ICU for ICI-related irAEs between January 2015 and May 2024. Overall survival was estimated using the Kaplan Meier method, and factors associated with ICU mortality were analyzed using Cox proportional hazards regression. RESULTS: Among 244 ICI-treated patients admitted to the ICU, 55 (23%) presented an irAE. The most frequent irAEs were myositis/myocarditis (29%) and pneumonitis (22%). Median time from first ICI infusion to irAE onset was 63 days [IQR 21-144]. Corticosteroids were initiated in 84% of cases, corresponding to 98% of treated patients; 39% were corticosteroid-refractory and 48% received additional immunosuppressive therapy. Half of the patients received vasopressors and 31% required mechanical ventilation. ICU mortality was 33%, mostly attributable to refractory irAEs. Corticosteroid refractoriness and mechanical ventilation were independently associated with ICU mortality (HR 12.32, 95% CI 3.26-46.52, p < 0.001; and HR 3.59, 95% CI 1.15-11.24, p = 0.028, respectively). CONCLUSION: This large ICU cohort of life-threatening irAEs reports high morbidity and mortality, particularly in patients with myositis, myocarditis, and pneumonitis. Corticosteroid refractoriness and mechanical ventilation were independently associated with ICU mortality. Early recognition, rapid escalation of care, and aggressive management may improve outcomes.
Drehmer L, Neto FLD, Ferrazza A
… +16 more, Paviani TF, Dos Santos Gomes A, de Moraes Rocha DB, Pasqual HM, Mariani PE, da Silva SBC, Albino CG, Mattioni MF, Reinheimer BMCB, Feltes IC, Soares FLL, do Bem CFP, Fior BR, Viana FC, Madeira LC, Teixeira C
J Crit Care
· 2026 Jun · PMID 42285015
·
Publisher ↗
INTRODUCTION: Sleep disruption is common in intensive care units (ICUs) and is associated with adverse outcomes. We evaluated whether a multidisciplinary sleep protocol improves subjective sleep quality in critically ill...INTRODUCTION: Sleep disruption is common in intensive care units (ICUs) and is associated with adverse outcomes. We evaluated whether a multidisciplinary sleep protocol improves subjective sleep quality in critically ill patients. METHODS: This multicenter quasi-experimental before-after study (2022-2024) was conducted in two Brazilian ICUs. Adult patients with an ICU stay of ≥2 nights were included. Sleep was assessed using the Richards-Campbell Sleep Questionnaire (RCSQ) and the Sleep in the ICU Questionnaire (SICUQ). Following baseline assessment, structured training and a multifaceted "ABCDEF of Sleep" protocol were implemented. The primary outcome was the global RCSQ score; secondary outcomes included SICUQ domains and clinical outcomes. RESULTS: A total of 112 patients were included (control = 61; intervention = 51). The primary outcome (aggregated 3-night RCSQ score) did not differ between groups (p = 0.31). In per-night analyses, RCSQ scores were higher on the second night in the intervention group (p = 0.008), with no differences on nights 1 or 3. The intervention improved perceived sleep quality and reduced environmental disturbances (p ≤ 0.001), without effects on mortality, mechanical ventilation, or length of stay. Family-reported sleep perception did not differ between groups. CONCLUSIONS: A pragmatic sleep protocol improved subjective sleep quality and reduced environmental disturbances in ICU patients, but did not impact major clinical outcomes. Larger studies using objective measures are needed.
Peña-López LA, Ortiz-Ruiz G, Garay-Fernández M
… +3 more, Parada-Gereda HM, Ballesteros D, Ramírez-Guerrero G
J Crit Care
· 2026 Jun · PMID 42276026
·
Publisher ↗
We thank Tang for the thoughtful comments regarding our review on extracorporeal CO₂ removal (ECCO₂R) in acute respiratory distress syndrome (ARDS). In this reply, we further discuss several key issues related to the phy...We thank Tang for the thoughtful comments regarding our review on extracorporeal CO₂ removal (ECCO₂R) in acute respiratory distress syndrome (ARDS). In this reply, we further discuss several key issues related to the physiological rationale and future development of ECCO₂R. While acknowledging the relevance of mechanical power (MP) as an integrative measure of ventilatory energy, we argue that variables such as driving pressure (ΔP) and ventilatory ratio (VR) may provide more actionable physiological information for identifying patients most likely to benefit from ECCO₂R. We review evidence supporting physiology-based patient selection, including predictive enrichment strategies derived from the SUPERNOVA and REST studies, and emphasize the importance of ventilatory burden, dead-space burden, and respiratory mechanics as determinants of treatment response. We also address the biological and physiological heterogeneity of ARDS, highlighting the need for individualized decisionmaking rather than universal selection criteria. Regarding treatment timing, we agree that earlier implementation may be physiologically advantageous, although optimal initiation thresholds remain uncertain. Finally, we discuss the emerging role of hybrid ECCO₂R-continuous renal replacement therapy (CRRT) platforms within the broader framework of multiple organ support therapy. Although the physiological rationale for these approaches is compelling, current evidence remains limited and heterogeneous. Overall, we contend that the future of ECCO₂R will depend on improved physiological patient selection, technological refinement, and a more precise understanding of responder phenotypes.