J Crit Care
· 2026 Jun · PMID 42269323
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OBJECTIVE: To investigate factors associated with mortality in critically ill COVID-19 patients at 3640 m above sea level (m.a.s.l.), focusing on the interaction between altitude-induced secondary erythrocytosis and viru...OBJECTIVE: To investigate factors associated with mortality in critically ill COVID-19 patients at 3640 m above sea level (m.a.s.l.), focusing on the interaction between altitude-induced secondary erythrocytosis and virus-induced hyperviscosity. METHODS: We conducted a retrospective cohort study of 59 adult patients with severe ARDS admitted to the ICU in La Paz, Bolivia. Severe ARDS was defined using altitude-adapted criteria. RESULTS: Non-survivors exhibited significantly higher median hematocrit (53.4% vs 49.7%; p = 0.0001) and D-dimer (29,729 vs 16,521 ng/mL; p = 0.0001) compared to survivors. An "APACHE II paradox" was observed, as survivors had significantly higher admission scores than non-survivors (24 vs 17; p = 0.01). While initial ventilatory mechanics were comparable (14.3 vs 14.1 cm H₂O; p = 0.81), non-survivors experienced exclusive complications, including pneumothorax (24.2%) and pulmonary embolism (18.2%). CONCLUSIONS: Hyperviscosity, exacerbated by altitude-induced erythrocytosis, is a primary factor associated with mortality in this environment. Traditional severity scores may not adequately stratify risk in high-altitude contexts, highlighting the need for altitude-specific protocols focusing on rheological control.
Mousa A, Plantinga C, Vignon P
… +17 more, Klompmaker P, Bos LDJ, Chew MS, Duška F, Galarza L, Goffi A, Hunsicker O, Klooster GV, Mongodi S, Olusanya S, Robba C, Smeulers M, Vieillard-Baron A, Visser A, Wong A, Smit MR, Tuinman PR
J Crit Care
· 2026 Jun · PMID 42269322
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INTRODUCTION: Critical care ultrasound (CCUS) is an essential tool for managing critically ill patients at bedside, improving diagnostic accuracy and reducing procedural risks. However, its global adoption remains incons...INTRODUCTION: Critical care ultrasound (CCUS) is an essential tool for managing critically ill patients at bedside, improving diagnostic accuracy and reducing procedural risks. However, its global adoption remains inconsistent due to variability in training, certification, and organizational support. This study explores current CCUS use, training practices, and associated facilitators and barriers, aiming to identify opportunities for improving its implementation. METHODS: A worldwide online survey was conducted between June 2023 and June 2024. The survey was endorsed and distributed by several (inter)national critical care societies. Participation was fully anonymous and open to all healthcare professionals affiliated with a critical care department. The survey consisted of four sections: demographic data, CCUS practice, CCUS training, and possible facilitators and barriers to CCUS. Facilitators and barriers were assessed using an evidence-based framework: the Measurement Instrument for Determinants of Innovation (MIDI). RESULTS: A total of 277 participants (73.3% intensivists, 60.3% European) across 62 countries completed the survey. Most participants (93.5%) used CCUS, predominantly for lung, vascular and basic cardiac assessments (>95% for each). However, the majority lacked formal CCUS certification (73.6%). Facilitators included CCUS's perceived value in improving patient outcomes, including faster diagnosis or treatment. Key barriers included lack of adequate training, absence of formal certification, and limited organizational support. CONCLUSION: Despite widespread recognition of CCUS's clinical benefits, significant barriers in training, certification, and organizational infrastructure hinder its full implementation. Addressing these challenges and engaging identified facilitators provides a strong foundation for promoting the introduction and integration of CCUS into routine clinical practice.
Basnet S, Sun K, Magder LS
… +2 more, Shanholtz C, Gandotra S
J Crit Care
· 2026 Jun · PMID 42269321
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BACKGROUND: Interhospital transfer of patients with sepsis is common, yet its impact on organ dysfunction trajectories remains unclear. Our study aims to evaluate the evolution of organ dysfunction between transferred an...BACKGROUND: Interhospital transfer of patients with sepsis is common, yet its impact on organ dysfunction trajectories remains unclear. Our study aims to evaluate the evolution of organ dysfunction between transferred and non-transferred patients presenting with community-onset sepsis. STUDY DESIGN AND METHODS: We conducted a retrospective cohort study of adults (≥18 years) presenting with community-onset sepsis between January 2017 and December 2020. Patients were either admitted locally or transferred to a referral center. Propensity score matching (1:1) was performed to balance baseline characteristics. The primary outcome was change in Sequential Organ Failure Assessment (SOFA) score from emergency department presentation to 72 h (ΔSOFA). Secondary outcomes included change in maximum SOFA at 48 and 96 h. Appropriate paired statistical tests were applied to matched cohorts. RESULTS: Among 6264 patients, 60 (0.95%) were transferred. After matching, 56 patients were included in each group. Transferred patients had higher ICU admission rates prior to matching (26.7% vs 8.8%, p < 0.001). In the matched cohort, transferred patients demonstrated greater improvement in organ dysfunction, with a larger reduction in ΔSOFA at 72 h (mean difference - 1.25; 95% CI -2.37 to -0.13; p = 0.03) and ΔSOFA max at 48 h (-1.14; 95% CI -2.23 to -0.06; p = 0.04). No significant differences were observed at 96 h. CONCLUSION: In this propensity-matched analysis, interhospital transfer was associated with greater early improvement in organ dysfunction among patients with community-onset sepsis.These findings suggest that access to higher-level care may influence early organ failure trajectories, though residual confounding cannot be excluded.
Markus M, Warner L, Karner V
… +7 more, Bhuiyan Z, Daum N, Beck E, Bald A, Pohrt A, Hodgson C, Schaller SJ
J Crit Care
· 2026 Jun · PMID 42247934
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BACKGROUND: Early mobilisation in the intensive care unit (ICU) is associated with improved patient outcomes. The Intensive Care Unit Mobility Scale (IMS) is established for rapid bedside assessment of patient mobilisati...BACKGROUND: Early mobilisation in the intensive care unit (ICU) is associated with improved patient outcomes. The Intensive Care Unit Mobility Scale (IMS) is established for rapid bedside assessment of patient mobilisation, but its predictive validity and interrater reliability have not been evaluated in German-speaking ICUs. METHODS: In a prospective, single-centre observational study, the German translation of the IMS was validated in a 21-bed anaesthesiology-led ICU. The IMS was assessed by nurses, physical therapists, residents and attending physicians, three times daily. Clinical endpoints included ICU and hospital length of stay (LOS), 90-day mortality, and functional outcomes at discharge (grip strength, Medical Research Council Sum Score (MRC-SS)). Interrater reliability (IRR) was calculated for the German IMS. RESULTS: A total of 100 patients were included. Higher mean IMS during ICU stay independently predicted shorter hospital LOS (Incidence Rate Ratio: 0.90, 95% CI (0.82, 0.95); p = 0.004) and lower 90-day mortality (Odds Ratio: 0.47; 95% CI (0.30, 0.74); p = 0.002). Higher discharge IMS correlated with improved functional outcomes (grip strength, MRC-SS), lower risk of ICU-acquired weakness (ICUAW), and reduced 90-day mortality. IRR was excellent, exceeding 0.95 across all professional categories. CONCLUSION: The German IMS demonstrates robust predictive validity and exceptional interrater reliability in a multiprofessional ICU setting. Both sustained mobilisation throughout the ICU stay and higher mobilisation at discharge are associated with shorter hospital stays, reduced mortality, and better functional recovery. These findings support routine integration of the IMS into ICU practice to guide targeted mobilisation strategies and improve patient outcomes.
Rehn P, Koos B, Witowski A
… +24 more, Wappler F, Henzler D, Seidlitz S, Maier-Hein L, Katzenschlager S, von Garrel A, Hölzl K, Hölle T, Full P, Theobald V, Niehaus B, Hölzer HT, Vekla C, Pätzold I, Thome S, Bösing C, Krebs J, Decker S, Fischer D, Schmitt FCF, Weigand MA, Adamzik M, Nowak H, Dietrich M
J Crit Care
· 2026 Jun · PMID 42242063
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BACKGROUND: Optimal ventilator strategies for septic patients remain uncertain, particularly regarding positive end-expiratory pressure (PEEP). While PEEP may affect hemodynamics through changes in intrathoracic pressure...BACKGROUND: Optimal ventilator strategies for septic patients remain uncertain, particularly regarding positive end-expiratory pressure (PEEP). While PEEP may affect hemodynamics through changes in intrathoracic pressure, its impact on clinical outcomes in sepsis is not well understood. This multi-cohort study explores the impact of higher versus lower PEEP settings on mortality and hemodynamics in sepsis. METHODS: We conducted a secondary analysis of 844 septic patients requiring mechanical ventilation across three cohorts (one multicentric prospective = Hyspec ICU, one monocentric prospective = SepDataNet, one monocentric retrospective = RetroSep). Patients were stratified into low PEEP groups according to the ARDSnet low PEEP table and high PEEP groups with PEEP levels above mentioned table. Primary endpoint was ICU or 30-day mortality depending on reported outcome data. Secondary endpoints included vasopressor requirement, lactate levels and fluid balance. RESULTS: In two cohorts, higher PEEP was associated with significantly lower mortality (RetroSep: 39.4% vs. 50.4% for ICU-mortality, p = 0.008; Hyspec-ICU: 22% vs. 41.7% for 30-day mortality, p = 0.029). The difference persisted after propensity score matching in the RetroSep cohort (38.4% vs. 49.4%; p = 0.046). Hemodynamic parameters such as lactate and vasoactive-inotropic scores were similar or improved in high PEEP groups. Hyperspectral imaging showed no adverse microcirculatory effects. CONCLUSION: In this multi-cohort analysis, higher PEEP (above ARDSnet low PEEP table) was associated with improved survival without evidence of hemodynamic deterioration. However, due to the observational nature of this analysis and possible confounders, the results should be considered hypothesis-generating and warrant confirmation in randomized trials.
Ohnuma T, Fuller M, Balamurugan P
… +4 more, Moehring R, Krishnamoorthy V, Raghunathan K, Treggiari MM
J Crit Care
· 2026 Jun · PMID 42224805
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PURPOSE: The implementation of early antibiotic de-escalation and its outcomes among patients with suspected bacterial culture-negative sepsis remain poorly characterized. The objective of this study was to evaluate whet...PURPOSE: The implementation of early antibiotic de-escalation and its outcomes among patients with suspected bacterial culture-negative sepsis remain poorly characterized. The objective of this study was to evaluate whether antibiotic de-escalation was associated with 30-day mortality while accounting for early changes in severity of illness. METHODS: We conducted a retrospective cohort study of adult patients with community-onset sepsis and negative bacterial cultures using Duke Health System data between 2016 and 2023. Sepsis was defined using the CDC Adult Sepsis Event criteria. Antibiotic change was assessed within 5 days of onset. De-escalation was defined as a reduction in antibiotic rank across 4 spectrum-based categories, discontinuation of anti-MRSA antibiotics, or reduction in the number of antibiotics. The cohort was stratified by SOFA score change from day 1 to day 3 as SOFA-improved (≤ - 2), SOFA-unchanged (-1 to 1), or SOFA-deteriorated (≥ + 2). RESULTS: A total of 7741 patients met the inclusion criteria; 33% showed improved SOFA scores, 59% had unchanged scores, and 8% had worsened scores. Overall, antibiotic de-escalation occurred in 4806 patients (62%). The crude 30-day mortality rate was 17%. In multivariable regression analyses, antibiotic de-escalation was not associated with 30-day mortality (adjusted OR 0.92; 95% CI 0.79-1.07). Findings were similar across SOFA change strata. CONCLUSION: Approximately two thirds of patients with suspected bacterial culture-negative sepsis underwent antibiotic de-escalation, suggesting potential opportunities to optimize antimicrobial stewardship. Antibiotic de-escalation was not associated with increased 30-day mortality across SOFA change groups.
J Crit Care
· 2026 May · PMID 42214943
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This letter comments on the study by Zerem et al. regarding long-term outcomes after obstetric ICU admission. While the topic is clinically important, several methodological limitations may affect the validity of the con...This letter comments on the study by Zerem et al. regarding long-term outcomes after obstetric ICU admission. While the topic is clinically important, several methodological limitations may affect the validity of the conclusions, including recall bias, selection bias, residual confounding, and reliance on screening tools without clinical confirmation. In addition, the cross-sectional design does not support inference on recovery trajectories over time. Prospective longitudinal studies with rigorous confounding control and clinically validated psychiatric assessment are needed to better define the long-term burden of obstetric critical illness.
J Crit Care
· 2026 May · PMID 42202622
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This letter comments on the recent prospective study by Kitisin et al. regarding the utility of the urine albumin-to-creatinine ratio (uACR) for acute kidney injury (AKI) risk stratification in critically ill patients. W...This letter comments on the recent prospective study by Kitisin et al. regarding the utility of the urine albumin-to-creatinine ratio (uACR) for acute kidney injury (AKI) risk stratification in critically ill patients. While commending the study's pragmatic approach, we propose three methodological refinements to optimize its clinical translation. First, we caution against applying chronic KDIGO diagnostic thresholds to hyper-acute physiological stress and recommend deriving ICU-specific cut-offs. Second, we highlight the necessity of continuous hemodynamic adjustment (e.g., Vasoactive Inotropic Score) to address cohort homogeneity. Finally, we address the clinical hazards of a negative event Net Reclassification Improvement (NRI) and advocate for metrics that penalize false negatives to prioritize bedside safety.