Critical Care Bulletin: January 2026

 

Spontaneous breathing trials as predictors of extubation outcomes in neurocritical care: insights from the ENIO study

Intensive Care Medicine | Published: 13 January 2026

 

 

Purpose

In critically ill patients, extubation readiness is typically assessed using a spontaneous breathing trial (SBT). Among patients with acute brain injury (ABI), the optimal SBT method remains uncertain.

Methods

We conducted a post-hoc analysis of the ENIO study (NCT03400904), including mechanically ventilated ABI patients with available SBT data, undergoing extubation attempt. SBTs were classified as T-piece, pressure support ventilation (PSV), or continuous positive airway pressure (CPAP). The primary outcome was extubation failure within 5 days. Associations between SBT modality and extubation failure were assessed using multivariable logistic regression and inverse probability of treatment weighting.

Results

Of 1,512 patients enrolled in ENIO, 839 met the inclusion criteria, of whom 270 (32.2%) were female and 396 (47.2%) had traumatic brain injury as the cause of admission. SBTs were performed with PSV in 430 (51.3%), T-piece in 329 (39.2%), and CPAP in 80 (9.5%). SBT median duration was 60 min in PSV and T-piece, while 120 min in CPAP. Extubation failure occurred in 177 (21.1%) cases. In multivariable analyses, there was no significant association between SBT modality or duration and extubation outcome. Results were similar in ABI subgroup analyses. After inverse probability weighting, vigorous cough remained the only significant predictor of extubation success.

Conclusions

In this large international ABI cohort, neither SBT mode nor duration was associated with extubation failure.

 

 

 

 

Severe community-acquired pneumonia: current concepts and controversies

Intensive Care Medicine | Published: 12 January 2026

Abstract

Community-acquired pneumonia, particularly in its severe forms (sCAP), remains a major public health problem due to its frequency, immediate and delayed complications, and the cost of treatment. Although rare, resistant pathogens could make it increasingly difficult to choose an empirical antibiotic treatment. Rapid molecular microbiological diagnostic techniques could help guide this choice, but their role needs to be better evaluated and their cost may be an obstacle to their widespread use. The duration of treatment tends to be decreasing, but could be guided by clinical progression and possibly biomarkers. As a disorder of dysregulated systemic inflammation, sCAP is potentially eligible for immunomodulatory treatment. Three recent high-powered randomized trials on corticosteroids have yielded conflicting results. There is a need to better define which patients are likely to benefit, perhaps those with a marked inflammatory syndrome, and in any case not those with influenza. Some macrolides also have a potential immunomodulatory effect. Other treatments are currently being investigated. Supportive care, particularly respiratory support, remains essential. It is not specific to sCAP and must be tailored to the severity of the patient's condition.

 

Temporary mechanical support in fulminant myocarditis: prognostic factors and clinical implications from the FULLMOON study

Intensive Care Medicine | Published: 12 January 2026

Background

Temporary mechanical circulatory support (t-MCS) is increasingly used in fulminant myocarditis (FM), yet long-term outcomes and risk factors remain poorly defined.

Methods

From the FULLMOON international cohort (419 adults with suspected FM across 36 centers in 15 countries), 295 patients treated with venoarterial extracorporeal membrane oxygenation (V-A ECMO) and/or Impella were analyzed. The primary endpoint was mortality at 1 year, heart transplantation (HTx), or left-ventricular assist device (LVAD). Multivariate Cox regression identified predictors of adverse outcomes. A propensity score-weighted analysis assessed outcomes based on timing of endomyocardial biopsy (EMB): early (≤ 2 days), delayed (> 2 days), or none.

Results

The median age was 39 years (IQR 28–60), and 55% were female. Myocarditis was confirmed in 204 (69%) of the patients via histology or cardiac MRI. Histological data were available for 151 (51%) of the cohort. One-year mortality was 36%, while 44% died or had an HTx or LVAD. Predictors of worse outcomes were giant cell myocarditis, older age, cardiac arrest at ECMO initiation, and delayed EMB. Delayed EMB was consistently associated with higher mortality, HTx, or LVAD compared to early (HR = 1.55; 95% CI 1.23–1.96; p < 0.01) or no EMB (HR = 1.59; 95% CI 1.26–2.01; p < 0.01). However, event-free survival did not differ significantly between early EMB and no EMB (HR = 1.03; 95% CI 0.80–1.32; p = 0.85).

Conclusions

Despite a relatively young cohort, FM requiring t-MCS is associated with a high 1-year mortality rate. Timely recognition and early referral to specialized ECMO centers before cardiac arrest are critical.

 

A consensus of international experts on definition, sampling, treatment, and prevention of peripheral extracorporeal membrane oxygenation cannula-site infection obtained by the Delphi method: the SAVECMO study

Intensive Care Medicine | Published: 08 January 2026

Background

Nosocomial infections are common in patients receiving extracorporeal membrane oxygenation (ECMO), with ECMO cannula-site infections (ECMO-CSI) being the most frequent infections directly related to the ECMO run. These infections can significantly impact patient outcomes. Currently, no adult guidelines exist for the prevention, diagnosis, and/or treatment of peripheral ECMO-CSI, resulting in heterogeneity in both clinical practice and research findings.

Methods

We conducted a Delphi study involving 39 international experts in ECMO management. The experts participated in four Delphi rounds to reach consensus on various aspects of ECMO-CSI complicating peripheral ECMO (central ECMO excluded), including definition, clinical suspicion, diagnostic methods, preventive measures, and treatment. Consensus was defined as ≥ 70% agreement among experts on each proposed item.

Results

The Delphi process established consensus on key aspects of ECMO-CSI. Experts agreed on clinical scenarios that warrant suspicion of ECMO-CSI, such as purulent discharge and local inflammatory signs. Standardized sampling techniques, including swabs and purulent drainage aspiration, were recommended, while others were rejected. Definitions were clarified, specifying that ECMO-CSI is defined by the isolation of a pathogen through local microbiological sampling and the presence of purulent discharge or local inflammatory signs. Among the preventive measures, the use of chlorhexidine-impregnated or semipermeable polyurethane dressings, unchanged for 7 days unless soiled or bleeding, was recommended, whereas systematic antibiotic prophylaxis, even for surgical ECMO, was not recommended.

Conclusion

This study presents an international expert consensus focusing on peripheral ECMO-CSI, providing a standardized framework to improve clinical management and facilitate future research. The consensus aims to enhance patient outcomes and support evidence-based guidelines in this complex field.

 

Cyclosporine versus placebo pretreatment of brain-dead donors and kidney graft function (Cis-A-Rein trial): a multicenter, double-blind, randomized, controlled trial

Intensive Care Medicine | Published: 08 January 2026

Purpose

Delayed graft function is the most frequent early complication of kidney transplantation. Pretreatment of kidney donors with cyclosporine has decreased delayed graft function in animal studies by reducing ischemia–reperfusion graft injuries. No randomized clinical trials have assessed the efficacy of cyclosporine pretreatment of brain-dead donors in reducing delayed graft function.

Methods

In this multicenter randomized, double-blind, and placebo-controlled trial, brain-dead donors were randomized (1:1) to receive either 2.5 mg/kg of cyclosporine or a glucose placebo infusion. The kidney transplant candidates were allocated through their donor assignment. The primary outcome was the occurrence of delayed graft function (DGF), defined as the need for at least one hemodialysis within the 7 days after kidney transplantation. Secondary outcomes included early graft function parameters within the 7 days post-transplantation, and 1-year graft and recipient survival.

Results

Between December 17, 2017 and March 3, 2023, 258 donors/331 recipients in the placebo group and 238 donors/312 recipients in the cyclosporine group were included in the modified intention-to-treat analysis. DGF occurred in 46 recipients (13.9%) in the placebo group and in 53 recipients (17.0%) in the cyclosporine group (unadjusted odd ratio = 1·27, 95% CI 0.83–1.95, P = 0.28). No significant between-group differences in the secondary outcomes (early graft function and 1-year graft and recipient survival) were observed.

Conclusion

In this double-blind, randomized controlled clinical trial, a pretreatment of brain-dead donors with a single low dose of cyclosporine did not significantly reduce the occurrence of DGF in kidney transplant recipients.

 

Family-administered delirium screening improves satisfaction among ICU caregivers: a prospective cohort study

Intensive Care Medicine | Published: 08 January 2026

Purpose

Family caregivers experience distress when their loved one is in the ICU, particularly in the setting of delirium. Limited English proficiency (LEP) may worsen this experience and contribute to long-term psychological burden. Yet, caregivers with LEP are rarely included in ICU research. Whether caregiver engagement using linguistically tailored delirium assessments improves satisfaction remains unknown.

Methods

We conducted a prospective cohort study in two academic ICUs evaluating delirium detection among English and Spanish-speaking ICU patients. Within this larger study, we performed a substudy of patient–caregiver dyads focused on caregiver satisfaction. Caregivers were assigned to: (1) FAM-CAM group, in which caregivers completed daily FAM-CAM delirium assessments, or (2) control group with no FAM-CAM exposure. All caregivers completed the Family Satisfaction in the ICU-24 (FS-ICU-24) after 3 days. Outcomes included overall satisfaction and subdomains of decision-making and care (0–100 scale). Independent t-tests compared satisfaction by language, FAM-CAM exposure, and patient delirium status.

Results

Among 120 dyads, 63 caregivers preferred English and 57 Spanish. English-speaking caregivers reported higher decision-making satisfaction than Spanish speakers (90.8 vs 85.6, p < 0.05). FAM-CAM exposure improved overall satisfaction across language groups (91.9 vs 84.4, p < 0.01). Patient delirium was linked to lower caregiver satisfaction, but FAM-CAM engagement mitigated this effect, with higher scores among exposed caregivers (90.9 vs 80.3, p < 0.05).

Conclusions

English-speaking caregivers reported higher satisfaction scores than Spanish-speaking caregivers. Engagement with FAM-CAM improved satisfaction across language groups, highlighting its potential to enhance caregiver engagement and promote equity in the ICU.

 

Challenges and strategies in the care of older adults across the continuum of intensive and post-intensive care medicine

Intensive Care Medicine | Published: 22 December 2025

Abstract

Older adults have composed more than half of ICU patient-days for the past 25 years, and these numbers are only expected to grow as the worldwide population of older adults doubles by 2050. For older adults, conditions such as frailty, disability in functional activities, and multimorbidity are more strongly associated with ICU and post-ICU outcomes than chronological age, and recent work shows that the prevalence of these conditions among older ICU patients is increasing over time. In response to this demographic shift, the science of aging-focused critical care has rapidly expanded over the past decade, and we now know more about how to care for older ICU patients than ever before. However, challenges in the care of older adults across the continuum of ICU and post-ICU care remain. In this narrative review, we discuss these challenges, propose strategies and future research to address them, and discuss best practices for the care of older ICU patients in the context of the state of the science.

 

The medical management of acute respiratory distress syndrome

Intensive Care Medicine | Published: 22 December 2025

Abstract

Despite advancements in bedside monitoring and paradigm shifts in standard ventilatory practice, mortality from acute respiratory distress syndrome (ARDS) remains high. The recent Global ARDS definition adopts a more pragmatic approach enabling earlier identification across a broader patient spectrum, independent of the interventions being administered. Meanwhile, our understanding of managing this heterogeneous syndrome has shifted towards defining precise subgroups with shared therapeutic targets. Physiological, biological, and radiological phenotypes may modify the response to interventions previously showing indeterminate benefit, making them potentially central to future personalised ARDS management. This narrative review summarises core evidence for the medical and ventilatory management of ARDS, explores emerging concepts, and offers clinicians a framework for current best practice and a roadmap for possible future directions.

 

Disorders of consciousness diagnosis, interventions, and prognostication for the intensivist: Report of the 2025 ISICEM roundtable

Intensive Care Medicine | Published: 15 December 2025

Abstract

Disorders of consciousness (DoC) represent a spectrum of clinical conditions, including coma, unresponsive wakefulness syndrome, and the minimally conscious state, which may result from structural and non-structural brain injuries due to trauma, stroke, anoxia, infections of the brain, and other causes. Clinical management of patients with DoC is especially challenging in the critical care environment, where the level of consciousness, a key factor in determining the trajectory of recovery, may be obscured by sedation, analgesia, and other confounders. The 2025 International Symposium on Intensive Care and Emergency Medicine hosted a Roundtable of 18 expert clinicians and researchers to synthesise and discuss the latest evidence on acute DoC epidemiology, diagnosis, treatment, and prognosis. Here, we summarise the output of the Roundtable in the format of a roadmap with six steps related to identifying patients with DoC, assessing for and treating confounders, establishing a diagnosis and prognosis, selecting interventions, and effectively communicating with family. This roadmap provides practical, evidence-informed guidance to help intensivists navigate diagnosis, treatment, and prognostication in patients with acute DoC. Advances in structural and functional neuroimaging, electrophysiology, and blood-based biomarkers offer promise for refined diagnostics and prognostication, though their clinical translation remains limited.

Critical Care Bulletin: November 2025

 

Epidemiology of pain, delirium, psychiatric disorders, discomfort and sedation-analgesia management in the intensive care unit: a one-day nationwide study

Critical Care volume 29, Article number: 483 (2025) Published: 11 November 2025

Background

The administration of sedatives and analgesics in intensive care units (ICUs) has evolved significantly over the past 20 years, shifting from deep to light sedation strategies to minimize adverse effects. Despite this shift, substantial variability persists in sedation-analgesia practices. This study aimed to provide an updated national overview of sedation-analgesia management with a focus on discomfort assessment practices, including pain, delirium, anxiety, thirst, mood, and sleep disorders.

Methods

This was a one-day, multicenter, cross-sectional study conducted in French ICUs. Data were collected from all adult patients hospitalized in the ICU on the study day. A Unit-level survey documented ICU characteristics and sedation-analgesia protocols. Patient-level data included sedation levels, pain scores, and assessments of discomfort conditions. Statistical analyses were performed using descriptive methods and multilevel logistic regression.

Results

Among 258 French ICUs contacted, 128 units (50%) participated, enrolling 2,063 patients. Most ICUs were university-affiliated (54%) and mixed medical-surgical (58%); 63% had a written protocol for sedation-analgesia. Sedation and pain were assessed in 96% and 91% of ICUs, respectively. Light or no sedation was observed in 84% of patients, while 15% were deeply sedated – 63% of whom were misaligned with usual indications. Pain assessment was performed at rest in 90% of patients and during care in 62%. Pain prevalence increased with lighter sedation levels and during care. Hypnotics were used in 31% of patients, Mainly propofol and midazolam. Discomfort was reported in 44% of patients, mainly anxiety, sleep disorders, and thirst. Written protocols for sedation and analgesia were not associated with sedation depth, drug use, or delirium screening, but were linked to more frequent pain assessment at rest. Multivariable analyses showed that higher SOFA scores were associated with deep or misaligned deep sedation. The presence of a written protocol for sedation and analgesia reduced the risk of unassessed pain but was not associated with deep or misaligned deep sedation.

Conclusion

The shift toward lighter sedation has been successfully achieved; however, a broad spectrum of stressful symptoms persists, including pain, anxiety, thirst, and sleep disruption. These findings underscore the need for more effective strategies to optimize pain and overall patient comfort in non-deeply sedated ICU patients.

 

Association between controlled mechanical ventilation and systemic inflammation in acute hypoxemic respiratory failure: an observational cohort study

Critical Care volume 29, Article number: 482 (2025) Published: 11 November 2025

Background

In patients with acute hypoxemic respiratory failure, spontaneous breathing efforts may contribute to patient self-inflicted lung injury through increased ventilation inhomogeneity and systemic inflammation. Whether early transition to controlled mechanical ventilation (CMV) mitigates these effects remains uncertain.

Methods

This observational, prospective cohort study included 40 ICU patients with acute hypoxemic respiratory failure who initially breathed spontaneously. Based on clinical decisions, patients were managed with either continued spontaneous breathing (SB group, n = 12) or transitioned to CMV (CMV group, n = 28). Arterial blood gases, hemodynamics, plasma cytokines (IL-6 and IL-8), and ventilation distribution via electrical impedance tomography (EIT) were recorded at baseline and after 24 h. In the CMV group, intermediate time points (T2, T6, T12) were also assessed after intubation. The trial was registered in ClinicalTrials.gov (NCT03513809).

Results

In the CMV group, respiratory rate and heart rate decreased significantly over time. IL-6 levels dropped markedly from 305 ± 938 pg/mL at baseline to 27 ± 58 pg/mL at 24 h (p = 0.0195), accompanied by a significant improvement in oxygenation (PaO₂/FiO₂ from 140 ± 51 to 199 ± 67, p = 0.0004). EIT data showed improved ventilation distribution with increased end-expiratory lung impedance, decreased global inhomogeneity, and a shift in the center of ventilation toward dorsal regions. In contrast, the SB group showed no significant changes over 24 h in gas exchange, systemic inflammation, or EIT-derived parameters.

Conclusions

In patients with acute hypoxemic respiratory failure initially breathing spontaneously, transition to CMV was associated with reduced IL-6 levels and improved ventilatory homogeneity over 24 h. These exploratory findings indicate that connection to controlled mechanical ventilation was associated with reduced systemic inflammation, a relationship that warrants confirmation in larger prospective studies.

 

 

Toward optimal mechanical ventilation of the injured lung: the role of expiratory duration

Critical Care volume 29, Article number: 481 (2025) Published: 10 November 2025

Abstract

Positive pressure mechanical ventilation is a life-saving intervention for patients with acute respiratory distress syndrome (ARDS), but it can also increase mortality by causing ventilator-induced lung injury (VILI) if applied inappropriately. Although strategies like low-tidal volume ventilation and prone positioning have been shown to reduce mortality, the optimal patient-specific approach to mechanical ventilation in ARDS has yet to be identified. The worst manifestations of acute lung injury arise when fluid and proteins from the blood leak through a damaged blood-gas barrier, accumulating in the airspaces and impairing the ability of pulmonary surfactant to lower surface tension. This amplifies the ventilatory stresses in the lung tissues, which further damages the blood-gas barrier, leading to a vicious cycle of worsening injury. Studies suggest that VILI may be most effectively avoided by preventing the atelectrauma caused during inspiration by the forced reopening of lung units that close during each expiration. Atelectrauma is conventionally mitigated with positive end-expiratory pressure (PEEP), but it remains unclear if the algorithmic selection of PEEP leads to mortality reductions in ARDS. Animal studies, however, support the efficacy of exploiting the time-dependent nature of recruitment and derecruitment, for example through the use of brief expiratory durations that continually adapt to changing lung mechanics. Despite decades of research, it remains unclear how to minimize VILI in any given ARDS patient. Animal studies coupled with energy dissipation analysis indicate that the prevention of VILI requires, above all, avoidance of the atelectrauma caused by cyclic recruitment and derecruitment in the lung. In addition, the path to optimal mechanical ventilation in ARDS must be based not only on the amplitudes of the pressures applied to the lung but also on their temporal natures.

 

Intermediate Care Unit performance being properly assessed?

Critical Care volume 29, Article number: 480 (2025) Published: 10 November 2025

Abstract

Intermediate Care Units (ImCU) are worldwide considered as an intermediate setting of care between standard wards and intensive care units (ICU), specifically addressed to critically ill patients admitted from Emergency Departments, stepping down from ICUs or stepping up from general wards. ImCU formats vary considerably between institutions, missing univocal criteria of where they should be placed, how be formatted and staffed, what monitoring and treatments delivered, which patients admitted, and when discharged. Many published studies focused primarily on mortality as the main variable of interest, while the effects of ImCU implementations on healthcare costs, hospital governance and comprehensive inpatient outcomes remain controversial. A consensus on which measures should be most accurate and based on evidence is still lacking. Appropriate quality-of-care key indicators should concern structures, processes, outcomes and their relationships. The development of a multi-level framework to assess ImCU performance, tailored on resources and management of each specific reality, should consider their functional role on hospital macro-systems, warranting both by patient-level and system-level objectives to ensure effective benchmarking and to provide a substantial support to clinical practice.

 

Impact of frailty on mortality, functional outcome, and health status after out-of-hospital cardiac arrest: insights from the TTM2-trial

Intensive Care Medicine Published: 10 November 2025

Purpose

To explore the association of frailty with mortality, functional outcome, and health status after out-of-hospital cardiac arrest.

Methods

This is a cohort-based secondary analysis of the Targeted Hypothermia versus Targeted Normothermia after out-of-hospital cardiac arrest (TTM2) trial, an international, prospective, multicentre study. Frailty was assessed using the Clinical Frailty Scale (1–9): fit (1–3), prefrail (4), frail (5), and severely frail (6–9). Main outcomes were mortality and poor functional outcome (modified Rankin Scale 4–6) at 6 and 24 months. Additional outcomes included neuroprognostication, withdrawal-of-life-sustaining-therapies (WLST), functional decline (retrospectively reported pre-arrest versus 6 month Glasgow Outcome Scale Extended score), health status (EQ-5D-5L, EQ-VAS), and life satisfaction at 6 and 24 months.

Results

Of 1861 participants, 240 (13%) were prefrail, and 188 (10%) were frail or severely frail. Mortality and poor functional outcome increased significantly with greater frailty. Compared to fit participants, adjusted ORs (95% CI) for 6 month mortality were: prefrail 2.7 (1.8–3.8), frail 3.7 (1.9–7.1), and severely frail 8.9 (4.2–18.7); and poor functional outcome: prefrail 2.9 (1.9–4.2), frail 3.9 (1.9–8.1), and severely frail 35.4 (8.4–148.8). Severely frail participants underwent neuroprognostication less often (p < 0.001), while WLST was more common in the prefrail, frail and severely frail (p < 0.001). Prefrail and frail survivors tended to report more frequent functional decline and lower health status, though with individual variation.

Conclusion

Frailty was associated with a significantly increased risk of mortality and poor functional outcome after out-of-hospital cardiac arrest. Findings suggest more frequent functional decline and lower overall health status in frail survivors.

 

Handgrip strength association with weaning outcome in mechanically ventilated ICU patients: a systematic review and meta-analysis

Critical Care volume 29, Article number: 478 (2025) Published: 07 November 2025

Abstract

Weaning from mechanical ventilation is a critical process in the intensive care unit (ICU), and extubation failure remains associated with poor outcomes. ICU-acquired weakness has been identified as a risk factor for delayed weaning. Maximal handgrip strength (HGS) is a simple bedside measure proposed as a surrogate marker of global muscle strength. This systematic review and meta-analysis aimed to assess the association between HGS and weaning outcomes in ICU patients. A systematic search of MEDLINE, EMBASE, CINAHL, and Cochrane Library was conducted up to December 2024. We included prospective cohort studies assessing maximal HGS prior to extubation in mechanically ventilated adults, and its association with extubation failure, spontaneous breathing trial (SBT) failure, or weaning classification (simple, difficult, or prolonged). Meta-analyses pooled mean differences in HGS between outcome groups, and diagnostic accuracy was evaluated using a hierarchical summary ROC model. Risk of bias was assessed using the QUIPS tool. Seven studies were included in the review (n = 707 patients), and six in the meta-analysis. No significant difference in HGS was found between extubation failure and success (mean difference: − 3.62 kg; 95% CI: − 7.92 to 0.62). However, significantly lower HGS was associated with SBT failure (–3.00 kg; 95% CI: − 4.64 to − 1.36) and non-simple weaning (–3.94 kg; 95% CI: − 5.31 to − 2.58). Pooled sensitivity and specificity of HGS were 72% and 60% respectively, in predicting either extubation failure or non-simple weaning. Negative predictive values ranged from 90% to 95%, for 10% and 20% pre-test probability. Maximal HGS does not appear to significantly differentiate extubation success from failure Given the limited number of studies and their heterogeneity, further high-quality research is needed to clarify its prognostic value across different patient subgroups and timeframes.