J Crit Care
· 2026 Aug · PMID 42061180
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This letter offers methodological and interpretative reflections on the study by Fresilli and colleagues. We first identify a critical data inconsistency in Table 1, where variable counts far exceed the cohort size and r...This letter offers methodological and interpretative reflections on the study by Fresilli and colleagues. We first identify a critical data inconsistency in Table 1, where variable counts far exceed the cohort size and reported mean ages contradict the inclusion criteria, suggesting encounter-level rather than patient-level data extraction-a violation of fundamental statistical assumptions. Second, the site of infection, a well-established strong predictor of sepsis outcomes with known sex differences in distribution, was not adequately controlled for, potentially confounding the observed survival advantage in young women. Third, the paradoxical finding of higher 28-day mortality in older women cannot be fully explained by declining estrogen levels alone, but likely reflects a complex interplay of immunosenescence, comorbidity patterns, frailty, and treatment biases. We recommend that the authors clarify the unit of data extraction, perform infection site-stratified analyses, and adopt a multidimensional framework in future research to better elucidate the role of sex in septic shock outcomes.
J Crit Care
· 2026 Aug · PMID 42048766
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BACKGROUND: Artificial intelligence (AI) and computerized clinical decision support systems (CDSS) are increasingly applied in intensive care, yet their clinical impact remains uncertain, as most studies focus on model d...BACKGROUND: Artificial intelligence (AI) and computerized clinical decision support systems (CDSS) are increasingly applied in intensive care, yet their clinical impact remains uncertain, as most studies focus on model development rather than prospective evaluation. OBJECTIVES: To identify randomized controlled trials (RCTs) evaluating AI-based or CDSS interventions intended to influence real-time decision-making in adult intensive care units (ICUs) and to assess their effects on process and patient-centered outcomes. METHODS: We conducted a systematic review of randomized controlled trials (RCTs). PubMed, Embase, Cochrane CENTRAL, ScienceDirect, and IEEE Xplore were searched from inception to November 2025. Eligible studies evaluated AI-based or CDSS interventions in adult ICU patients. Study quality was assessed using RoB 2 and CONSORT-AI criteria. RESULTS: Ten RCTs were included, enrolling approximately 100,000 adult ICU patients. Five trials evaluated AI-based interventions and five evaluated CDSS. Eight trials showed improvements in at least one process measure, including earlier recognition of deterioration, improved protocol adherence, and physiological stability. However, patient-centered benefits were uncommon. Two trials reported reductions in mortality (a sepsis prediction model and a machine-learning-based early-warning system), while most studies showed no consistent effects on clinical outcomes. Reporting of AI-specific elements-dataset provenance, algorithm versioning, and human-AI interaction-was frequently incomplete. CONCLUSIONS: AI and CDSS interventions in adult ICUs are associated with improvements in process-related outcomes but show limited and inconsistent effects on patient-centered endpoints. These findings highlight a persistent gap between algorithmic innovation and clinical validation and underscore the need for pragmatic randomized trials with improved reporting and integration into clinical workflows.
Mehta AB, Day GL, Barocas JA
… +2 more, Hasnain-Wynia R, Douglas IS
J Crit Care
· 2026 Aug · PMID 42044608
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BACKGROUND: Noninvasive (NIV) failure (progression from NIV to intubation) is associated with high risk of death. Impaired patient-provider communication may increase risk of failure. We investigated associations between...BACKGROUND: Noninvasive (NIV) failure (progression from NIV to intubation) is associated with high risk of death. Impaired patient-provider communication may increase risk of failure. We investigated associations between primary spoken language (PSL) and NIV failure. METHODS: In this retrospective cohort study using the 2021 State Inpatient Database from California, Iowa, and Maryland, we identified adult patients treated with NIV. The primary exposure was PSL categorized as English, Spanish, or non-English/non-Spanish. Mixed-effects models were used to determine the adjusted odds (aOR) of NIV failure based on PSL. RESULTS: Among 57,215 patients who received NIV, 83.5% had English, 11.6% had Spanish, and 5.0% had non-English/non-Spanish PSL. Patients with Spanish PSL had higher incidence of NIV failure compared to English PSL (31.8% vs 20.3%, aOR = 1.63, 95% CI 1.52-1.74) but no difference was observed between non-English/non-Spanish PSL and English PSL (18.8% vs 20.3%, aOR = 1.08, 95% CI 0.97-1.20). NIV failure-related mortality was high. Patients with Spanish PSL with NIV failure died at higher rates compared to English PSL (69.7% vs 56.5%, aOR = 1.45, 95% CI 1.30-1.63) but no difference between non-English/non-Spanish PSL and English PSL (61.1% vs 56.5%, aOR = 0.99, 95% CI 0.81-1.20). The results were robust to multiple sensitivity analyses. CONCLUSIONS: NIV failure remains common and associated with high hospital mortality. Patients with Spanish PSL experience significantly higher odds of NIV failure and death compared to English PSL and even non-English/non-Spanish PSL. It is unclear why patients with Spanish PSL experience dramatically different outcomes compared to non-English/non-Spanish PSL. Future research should investigate if patients with Spanish PSL are less likely to receive formal interpreter services.
Sjöstedt H, Wellhagen A, Hvarfner A
… +8 more, Bjurling-Sjöberg P, Hintze C, Wärnberg MG, Castegren M, Baker T, Kurland L, Lipcsey M, Schell CO
J Crit Care
· 2026 Aug · PMID 42044607
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BACKGROUND: Inability to walk (IATW) has predicted mortality in emergency units and in low-income settings, but its value among inpatients in high-income countries is unknown. AIM: To evaluate the predictive accuracy of...BACKGROUND: Inability to walk (IATW) has predicted mortality in emergency units and in low-income settings, but its value among inpatients in high-income countries is unknown. AIM: To evaluate the predictive accuracy of IATW for 30-day in-hospital mortality among inpatients in a high-income country, compare its performance with NEWS CRITICAL (the threshold for urgent review), and assess whether IATW provides complementary risk stratification when combined with NEWS. METHODS: All adult inpatients in four Swedish hospitals were prospectively examined in a multicenter point-prevalence assessment. IATW was defined as inability to walk five steps without physical assistance or walking aids. NEWS was calculated from contemporaneous vital signs. The primary outcome was 30-day in-hospital mortality. We computed sensitivity, specificity, predictive values, and likelihood ratios. Multivariable logistic regression assessed the association between IATW and mortality, adjusted for NEWS, age, and sex. RESULTS: Of 1842 patients, 59.9% were IATW-positive and 22.3% met NEWS CRITICAL (≥5 or any single-parameter score of 3). Mortality was 4.6%. IATW had higher sensitivity (86.9% vs 66.7%) but lower specificity (41.4% vs 79.8%) than NEWS CRITICAL; NPV was high for both (98.5% vs 98.0%). IATW was independently associated with mortality after adjustment for NEWS (OR 2.43, 95% CI 1.24-4.76; p = 0.009). Patients that were both IATW-negative and with NEWS <5 (35.2% of the cohort) had 1.1% mortality. CONCLUSIONS: Inability to walk (IATW) is a bedside assessment that when negative identifies patients with low 30-day in-hospital mortality and provides complementary information to NEWS. Its low complexity, high sensitivity and low negative likelihood ratios support its use in clinical risk assessments.
J Crit Care
· 2026 Aug · PMID 42025595
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BACKGROUND: Inferior vena cava (IVC) distensibility is widely used to assess fluid responsiveness (FR) during passive positive pressure ventilation. However, interpretation of IVC dynamics during triggered breaths under...BACKGROUND: Inferior vena cava (IVC) distensibility is widely used to assess fluid responsiveness (FR) during passive positive pressure ventilation. However, interpretation of IVC dynamics during triggered breaths under assisted ventilation remains challenging. This study aimed to evaluate the effects of different pressure support ventilation (PSV) and positive-end expiratory pressure (PEEP) levels on IVC dynamics during triggered breaths. METHOD: This randomized crossover physiologic study included critically ill patients undergoing weaning from mechanical ventilation. Participants were exposed to four randomized sets of 12 PSV conditions combining different levels of pressure support (PS) and PEEP.IVC behavior during inspiration was assessed using ultrasound. The IVC collapsibility index (cIVC) and distensibility index (dIVC) were calculated. Respiratory effort was assessed using airway occlusion pressure at 100 milliseconds (P0.1). RESULTS: Sixty ICU patients were included. Inspiratory IVC collapse occurred in 85% of observations, particularly at lower PS/PEEP levels, whereas IVC distension predominated at higher settings. Among observations with IVC collapse, cIVC values were highest at lower PS/PEEP levels. Each 1-cmH2O increase in P0.1 was associated with an approximately 3.5%-point increase in cIVC, and mediation analysis showed that P0.1 accounted for nearly 40% of the association between PS settings and cIVC (38.5% [95% CI 19.2 to 57.7]). CONCLUSION: During PSV, inspiratory IVC collapse is common. The use of cIVC during patient-triggered breaths primarily reflects ventilator-patient interaction rather than preload alone and should be interpreted with caution. Future studies should account for respiratory effort when using cIVC to access FR under assisted ventilation.
Bagate F, Masi P, Cicetti M
… +2 more, Lapenta C, Mekontso Dessap A
J Crit Care
· 2026 Aug · PMID 41996775
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BACKGROUND: While the effects of fluid expansion (FE) on preload are well established, its impact on cardiac afterload and ventriculo-arterial coupling (VAC) remains less defined. This study aimed to assess the effects o...BACKGROUND: While the effects of fluid expansion (FE) on preload are well established, its impact on cardiac afterload and ventriculo-arterial coupling (VAC) remains less defined. This study aimed to assess the effects of FE on VAC and its components-arterial elastance (Ea) and left ventricular end-systolic elastance (Ees)-and to evaluate the influence of preload responsiveness. METHODS: In this prospective observational study conducted in a French ICU, patients with acute circulatory failure requiring FE (500 mL crystalloid bolus) were included. Transthoracic echocardiography was performed before and after FE to estimate VAC, Ea, and Ees using the single-beat method. Fluid responsiveness was defined as an increase ≥10% in the velocity-time integral of the left ventricular outflow tract. RESULTS: Thirty-eight patients were enrolled; 17 (45%) were fluid responders. At baseline, responders had higher Ea and Ees than non-responders, while VAC was comparable between groups. In the overall population, FE did not significantly modify VAC or its components. In responders, Ea decreased (1.63 [1.19-2.05] to 1.46 [1.10-1.96], p = 0.0007), whereas it increased in non-responders (1.31 [0.99-1.67] to 1.37 [1.02-1.78], p = 0.003). Ees remained unchanged. VAC improved significantly in responders (1.26 [0.82-1.63] to 1.09 [0.79-1.43], p = 0.03). Conclusion In acute circulatory failure, the effects of FE on VAC depend on preload responsiveness. Responders exhibit improved VAC driven by reduced Ea, while non-responders show increased Ea without significant VAC modification. Ees remains unaffected in both groups.
Hu L, Chen X, Huang X
… +5 more, Li H, Wu X, Tang R, Feng Z, Chen C
J Crit Care
· 2026 Aug · PMID 41985267
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BACKGROUND: Sepsis-associated acute kidney injury (SA-AKI) is a common and severe complication in critically ill patients, yet current risk stratification lacks immune-specific biomarkers. The CD4/CD8 T cell ratio, a key...BACKGROUND: Sepsis-associated acute kidney injury (SA-AKI) is a common and severe complication in critically ill patients, yet current risk stratification lacks immune-specific biomarkers. The CD4/CD8 T cell ratio, a key indicator of immune homeostasis, has shown prognostic value in sepsis, but its specific association with, and incremental value for predicting, SA-AKI risk in Chinese ICU populations remains underexplored. METHODS: In this single-center, multi-ICU retrospective cohort study, 349 adult septic patients were enrolled. The peripheral blood CD4/CD8 T-cell ratio was measured by flow cytometry within 24 h of ICU admission. Nonlinear associations were assessed using restricted cubic spline (RCS) analysis. Model performance was evaluated by area under the receiver operating characteristic curve (AUC), net reclassification improvement (NRI), integrated discrimination improvement (IDI), and decision curve analysis (DCA). Robustness was further assessed through sensitivity and subgroup analyses. RESULTS: A U-shaped relationship was observed between the CD4/CD8 ratio and SA-AKI risk, with the lowest risk at ratios of 1.5-2.5. The CD4/CD8-enhanced model significantly improved predictive performance compared to the clinical model alone (AUC: 0.788 vs. 0.738). Significant improvements in risk reclassification were confirmed by NRI (0.57, 95% CI: 0.40-0.74) and IDI (0.06, 95% CI: 0.03-0.09). DCA demonstrated superior clinical utility across a wide range of risk thresholds. CONCLUSIONS: This study establishes a U-shaped association between the CD4/CD8 ratio and SA-AKI risk, with the nadir of risk at a ratio of 1.5-2.5. These findings support integrating this readily available immune biomarker into risk stratification models to improve early identification of septic patients at high risk for AKI.
Mahmood A, Ahmed ES, Ahsan N
… +6 more, Aziz F, Atiq H, Khan MA, Durrani B, Kazi AM, Latif A
J Crit Care
· 2026 Aug · PMID 41965220
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INTRODUCTION: Low- and middle-income countries (LMICs), including Pakistan, face a high burden of critical illness but limited intensive care unit (ICU) capacity, compounded by financial and cultural barriers. Families p...INTRODUCTION: Low- and middle-income countries (LMICs), including Pakistan, face a high burden of critical illness but limited intensive care unit (ICU) capacity, compounded by financial and cultural barriers. Families play a central role in ICU decision-making, yet little is known about their perceptions. This study aims to explore Pakistani families' perceptions of intensive care and identify barriers affecting ICU utilization. METHODS AND ANALYSIS: Six focus group discussions were held with 38 family members across 10 public hospitals in three provinces. A semi-structured guide explored perceptions of ICU care, decision-making, affordability, and end-of-life experiences. Data were analyzed thematically using an inductive approach. RESULTS: Three themes and sixteen subthemes emerged. Families viewed ICU admission as a sign of impending death, causing significant psychological distress. While ventilators were understood as lifesaving, some associated them with harm. Major barriers included public bed shortages and prohibitive private costs, though insurance has improved access. Families prioritized active involvement in patient care but faced poor communication, mistrust in private hospitals, and discomfort with trainees. Conversely, 24-h senior physician coverage provided reassurance. Spiritual beliefs heavily influenced end-of-life decisions, often prompting care withdrawal to prevent suffering. CONCLUSION: Family perceptions of ICU care in Pakistan are defined by fear, financial constraints, spiritual values, and a strong desire for active participation. To build trust and support patient-centered care in low-resource settings, health systems must improve communication, facilitate family engagement, and ensure timely access to quality services.
J Crit Care
· 2026 Aug · PMID 41962419
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Dual-energy computed tomography (DECT) acquires images at two X-ray energy levels, enabling material differentiation beyond conventional single-energy CT. DECT generates iodine maps, virtual non-contrast images, and othe...Dual-energy computed tomography (DECT) acquires images at two X-ray energy levels, enabling material differentiation beyond conventional single-energy CT. DECT generates iodine maps, virtual non-contrast images, and other reconstructions that enhance diagnostic performance while reducing contrast dose and radiation exposure. These advantages are particularly relevant for critically ill patients, where accurate and rapid imaging with reduced contrast exposure can be organ or life saving. This review summarizes current evidence on DECT in critical care. In pulmonary embolism, DECT provides anatomical and functional assessment through iodine perfusion maps, improving detection of segmental and subsegmental emboli. In post-thrombectomy intracerebral hemorrhage, DECT can distinguish true hemorrhage from post-procedural contrast staining. In acute abdominal pathology, DECT can improve visualization of ischemia, inflammation, infection, and hemorrhage. In urolithiasis, DECT can identify uric acid stone composition, informing treatment selection. In aortic imaging, DECT may improve diagnostic confidence while enabling iodine dose reduction and substitution of true non-contrast scans with virtual alternatives. In musculoskeletal imaging, DECT accurately detects bone marrow edema, potentially reducing the need for magnetic resonance imaging when access is limited. DECT also has applications in tendon and ligament injury, and metal artifact reduction. Across these scenarios, DECT offers advantages over conventional CT in critical care, including material differentiation, functional assessment, and potential reductions in contrast dose and radiation exposure. It generally demonstrates high specificity and variable sensitivity, with the level of supporting evidence varying by indication, ranging from meta-analyses to small retrospective studies. Wider adoption will require standardized protocols, targeted training, and additional high-quality studies.