Critical Care Bulletin: February 2025

 

Relationship between skin microvascular blood flow and capillary refill time in critically ill patients

Critical Care volume 29, Article number: 57 (2025)

Published: 04 February 2025

Background

Capillary refill time (CRT) and skin blood flow (SBF) have been reported to be strong predictors of mortality in critically ill patients. However, the relationship between both parameters remains unclear.

Methods

We conducted a prospective observational study in a tertiary teaching hospital. All patients older than 18 years admitted in the intensive care unit (ICU) with circulatory failure and a measurable CRT were included. We assessed index SBF by laser doppler flowmetry and CRT on the fingertip, at T0 (Within the first 48 h from admission) and T1 (4 to 6 h later). Correlation was computed using Spearman or Pearson’s formula.

Results

During a 2-month period, 50 patients were included, 54% were admitted for sepsis. At baseline median CRT was 2.0 [1.1–3.9] seconds and median SBF was 46 [20–184] PU. At baseline SBF strongly correlated with CRT (R2 = 0.89; p < 0.0001, curvilinear relationship), this correlation was maintained whether patients were septic or not (R2 = 0.94; p = 0.0013; R2 = 0.87; p < 0.0001, respectively), and whether they received norepinephrine or not (R2 = 0.97; p = 0.0035; R2 = 0.92; p < 0.0001, respectively). Between T0 and T1, changes in SBF also significantly correlated with changes in CRT (R2 = 0.34; p < 0.0001). SBF was related to tissue perfusion parameters such as arterial lactate level (p = 0.02), whilst no correlation was found with cardiac output. In addition, only survivors significantly improved their SBF between T0 and T1. SBF was a powerful predictor of day-28 mortality as the AUROC at T0 was 85% [95% IC [76–91]] and at T1 90% [95% IC [78–100]].

Conclusion

We have shown that index CRT and SBF were correlated, providing evidence that CRT is a reliable marker of microvascular blood flow.

Trial registration Comité de protection des personnes Ouest II N° 2023-A02046-39.

 

Heterogeneity of treatment effect: the case for individualising oxygen therapy in critically ill patients

Critical Care volume 29, Article number: 50 (2025) 

Published: 28 January 2025

Abstract

Oxygen therapy is ubiquitous in critical illness but oxygenation targets to guide therapy remain controversial despite several large randomised controlled trials (RCTs). Findings from RCTs evaluating different approaches to oxygen therapy in critical illness present a confused picture for several reasons. Differences in both oxygen target measures (e.g. oxygen saturation or partial pressure) and the numerical thresholds used to define lower and higher targets complicate comparisons between trials. The duration of and adherence to oxygenation targets is also variable with consequent substantial variation in both the dose and the dose separation. Finally, heterogeneity of treatment effects (HTE) may also be a significant factor. HTE is defined as non-random variation in the benefit or harm of a treatment, in which the variation is associated with or attributable to patient characteristics. This narrative review aims to make the case that such heterogeneity is likely in relation to oxygen therapy for critically ill patients and that this has significant implications for the design and interpretation of trials of oxygen therapy in this context. HTE for oxygen therapy amongst critically ill patients may explain the contrasting results from different clinical trials of oxygen therapy. Individualised oxygen therapy may overcome this challenge, and future studies should incorporate ways to evaluate this approach.

 

Extremely early initiation of vasopressors might not decrease short-term mortality for adults with septic shock: a systematic review and meta-analysis

Annals of Intensive Care volume 15, Article number: 18 (2025)

Published: 27 January 2025

Background

The optimal timing for initiating vasopressor therapy in patients with septic shock remains unclear. This study aimed to assess the impact of early versus late vasopressor initiation on clinical outcomes.

Methods

A systematic review and meta-analysis were conducted by searching PubMed, Embase, and Cochrane databases. Studies comparing early and late vasopressor administration in septic shock patients were included. The primary outcome was short-term mortality, and subgroup analyses were performed based on different initiation timings.

Results

Eleven studies with 6,661 patients were included. Different studies define the ‘early administration’ timeframe variously, ranging from one to seven hours. No significant difference in short-term mortality was observed between early and late administration in the combined analysis of 3,757 patients from two RCTs and three quasi-experimental studies (OR: 0.66, 95% CI: [0.36, 1.19], I²: 82%). However, lower mortality was found in subgroups with early but not extremely early initiation (one to three hours, OR: 0.70, 95% CI: [0.60, 0.82], I²: 0%), and those using septic shock diagnosis as time zero (OR: 0.64, 95% CI: [0.48, 0.85], I²: 39%).

Conclusion

Our findings found that earlier initiation of vasopressor therapy, particularly within one to three hours after the diagnosis of septic shock, may be associated with reduced short-term mortality in certain subgroups. However, due to the heterogeneity in study definitions and potential confounding factors, these results should be interpreted cautiously. Further standardized investigations are warranted to precisely determine the optimal timing for vasopressor initiation to maximize survival outcomes in patients with septic shock.

 

Sex disparities in ICU care and outcomes after cardiac arrest: a Swiss nationwide analysis

Critical Care volume 29, Article number: 42 (2025) 

Published: 23 January 2025

Background

Conflicting data exist regarding sex-specific outcomes after cardiac arrest. This study investigates sex disparities in the provision of critical care and outcomes of in-hospital (IHCA) and out-of-hospital cardiac arrest (OHCA) patients.

Methods

Analysis of adult cardiac arrest patients admitted to certified Swiss intensive care units (ICUs) (01/2008–12/2022) using the nationwide prospective ICU registry. The primary outcome was ICU mortality, with secondary outcomes including ICU admission probability and advanced treatment provision.

Results

Among 41,733 individuals (34.9% women), 21,692 patients (30.6% women) were admitted to ICUs (16,571 OHCA patients/5121 IHCA patients). Women were less likely to be admitted to the ICU than men (incidence rate ratio 0.82 [95% CI 0.80–0.85] and had a higher ICU mortality (41.8% vs 36.2%; p < 0.001). Mortality differences were more pronounced in OHCA patients (unadjusted HR: 1.35 [95% CI 1.28–1.43]; adjusted HR: 1.19 [95% CI 1.12–1.25]). In IHCA patients, mortality differences were less pronounced (unadjusted HR: 1.14 [95% CI 1.04–1.25]) and vanished after adjustment for confounders: adjusted HR: 1.03 [95% CI 0.94–1.13]). Women after cardiac arrest were older, more severely ill, and received fewer interventions before (44.7% vs 54.0%; p < 0.001) and during ICU stay. A subgroup analysis of 11,202 patients revealed that treatment limitations were more frequent in women (46.7% vs 38.7%; p < 0.001). However, these limitations were associated with an increased risk of death in both sexes.

Conclusions

This study highlights sex disparities in short-term mortality and ICU resource allocation among cardiac arrest patients, with women potentially facing disadvantages, in particular after OHCA. The limitations of ICU registry data, particularly the lack of detailed cardiac arrest-specific and comorbidity information, restrict definitive conclusions. Future research should prioritize prospective studies with more granular data to better understand and address these disparities.

 

The association between pain, analgesia, and delirium among critically ill adults: a systematic review and meta-analysis

Intensive Care Medicine

Published: 22 January 2025

Purpose

We performed a systematic review with meta-analysis examining the relationship between pain or pain medications and delirium occurence, duration, and severity.

Methods

We searched MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials from inception to May 15, 2023. We included randomised or observational studies among critically ill adults, that reported data on pain or exposure to analgesics, and reported delirium presence, duration, or severity with no language or region restrictions. PROSPERO ID: CRD42022367715. Two authors independently screened records and extracted data. Risk of bias was evaluated using Risk of Bias 2 or the Risk of Bias In Non-randomized Studies of Interventions. We pooled data using the Hartung-Knapp Sidik-Jonkmann random effects model. PRISMA was followed.

Results

From 8,054 citations, 90 studies (119,230 patients) published between 2001 and 2023 were included in the systematic review. 41 studies were included in the primary meta-analysis examining prevalent delirium: seven studies evaluated pain; 12 studies evaluated fentanyl; and five studies evaluated morphine. There was a trend to association between pain and delirium occurrence (OR 2.49, 95% CI 0.98–6.30), and a significant association between pain and incident delirium (OR 3.70, 95% CI 1.73–7.93). Fentanyl (OR 2.49, 95% CI 1.45–4.27) and morphine (OR 2.13, 95% CI 1.21–3.75) were associated with delirium occurrence. Risk of bias was critical for many studies.

Conclusions

We observed an association between pain and incident delirium among critically ill adults. Exposure to morphine or fentanyl (but no other pain medications) was associated with increased risk of delirium occurrence.

 

The role of phospholipid transfer protein in sepsis-associated acute kidney injury

Critical Care volume 29, Article number: 33 (2025) 

Published: 20 January 2025

Background

Phospholipid transfer protein (PLTP), a glycoprotein widely expressed in the body, is primarily involved in plasma lipoprotein metabolism. Previous research has demonstrated that PLTP can exert anti-inflammatory effects and improve individual survival in patients with sepsis and endotoxemia by neutralizing LPS and facilitating LPS clearance. However, the role of PLTP in sepsis-associated acute kidney injury (SA-AKI) and the specific mechanism of its protective effects are unclear. This study aimed to assess the potential role of PLTP in SA-AKI.

Methods

This is a population-based prospective observational study of patients with sepsis admitted to the intensive care unit. Blood samples were collected on days 1, 3, 5, and 7 after admission to the ICU. Plasma PLTP lipotransfer activity was measured to assess outcomes, including the incidence of SA-AKI and 30-day major adverse kidney events (MAKE 30). The correlation between PLTP lipotransfer activity and SA-AKI and MAKE 30 was evaluated through logistic regression modeling. Receiver operating characteristic curves were used to assess the diagnostic value of PLTP lipotransfer activity for SA-AKI and MAKE 30. The PLTP lipotransfer activity was categorized into high and low groups based on the optimal cut-off values. The differences between the high and low PLTP lipotransfer activity groups in terms of MAKE 30 were evaluated using Kaplan–Meier analysis. The SA-AKI mouse model was established via cecum ligation and puncture (CLP) in the animal experimental phase. The impact of PLTP on renal function was then investigated in wild-type and PLTP ± mice. The wild-type mice were given recombinant human PLTP (25 μg, 200 μL each/dose) via the tail vein at 1-, 7-, and 23-h intervals on the day preceding CLP. The control group received an equal volume of solvent. The 10-day survival and kidney function among the treatment groups were then evaluated.

Results

A total of 93 patients were enrolled in this clinical trial, of which 52 developed acute kidney injury (AKI). A total of 32 patients died over the course of the 30-day follow-up period, 34 underwent kidney replacement therapy, 37 developed persistent acute kidney injury, and 55 patients met the composite endpoint. The plasma PLTP lipotransfer activity was identified as an independent predictor of SA-AKI (crude OR = 0.96, 95% CI 0.95–0.98, p < 0.001; adjusted OR = 0.92, 95% CI 0.86–0.96, p = 0.001) and MAKE 30 (crude OR = 0.97, 95% CI 0.96–0.98, p < 0.001; adjusted OR = 0.96, 95% CI 0.93–0.98, p = 0.001). The area under the curve (AUC) of plasma PLTP lipotransfer activity within 24 h of ICU admission could predict the occurrence of SA-AKI and MAKE 30 in septic patients (AUC values; 0.87 (95% CI 0.79–0.94) and 0.87 (95% CI 0.80–0.94), respectively). The cumulative incidence of main kidney adverse events was significantly lower in the high group than in the low group (p < 0.001). Compared with the controls, creatinine levels were significantly elevated in the CLP mice, while PLTP lipotransfer activity was significantly decreased at 24 h postoperatively. Moreover, the PTLP ± mice exhibited significantly impaired renal function and markedly elevated plasma levels of inflammatory mediators compared with the wild-type CLP mice. Notably, human recombinant PTLP significantly prolonged 10-day survival, improved renal function, and attenuated mitochondrial structural damage in wild-type CLP mice.

Conclusions

These findings indicate that PLTP is a potential therapeutic target in sepsis-associated acute kidney injury.

 

Impact of frailty and older age on weaning from invasive ventilation: a secondary analysis of the WEAN SAFE study

Annals of Intensive Care volume 15, Article number: 13 (2025)

Published: 20 January 2025

Objective

To understand the impact of both frailty and chronologic age on outcomes of weaning from invasive mechanical ventilation (MV).

Methods

The study population consisted of patients enrolled in the ‘WorldwidE. AssessmeNt of Separation of pAtients From ventilatory assistancE (WEAN SAFE) study. We defined 4 non-overlapping groups, namely: ‘frail’ (clinical frailty scale [CFS] score > 4; age < 80 years); ‘elderly’ (CFS ≤ 4; age ≥ 80y), ‘frail \elderly’ (CFS > 4; age ≥ 80 years), and a ‘not frail or elderly’ population. The primary outcome was the impact of frailty and older age on delayed weaning and failed weaning from invasive MV. Secondary outcomes included the impact of frailty and age on ICU and hospital survival.

Results

In the study population, 760 (17%) were frail, while 360 (8%) were elderly, 197 (4%) were frail and elderly, while 3,176 (70%) were not frail or elderly. The frail and elderly cohorts were more likely to be female, had hypoxemic/hypercapnic respiratory failure or sepsis, and had more comorbidities. The proportion of delayed weaning and of failed weaning from invasive MV was significantly higher in the frail (28 and 23%), the elderly (25 and 19%), and the frail and elderly groups (22% and 25%), compared to the not frail or elderly population (12% and 13%, P < 0.01). ICU and hospital mortality was higher in the frail (21 and 33%), the elderly (19 and 31%), and the frail and elderly groups (26 and 46%), compared to the not frail or elderly population (12% and 18%, P < 0.001). In multivariate analyses, there was an independent association between frailty and delayed weaning initiation and weaning failure. Old age was independently associated with risk of weaning failure.

Conclusions

Frailty status had a more consistent impact than older age on weaning outcomes. However, overall outcomes in these cohorts are encouraging once separation attempts have been initiated.

 

 

Cardiovascular effects of lactate in healthy adults

Critical Care volume 29, Article number: 30 (2025) 

Published: 17 January 2025

Background

Low-volume hypertonic solutions, such as half-molar lactate (LAC), may be a potential treatment used for fluid resuscitation. This study aimed to evaluate the underlying cardiovascular effects and mechanisms of LAC infusion compared to sodium-matched hypertonic sodium chloride (SAL).

Methods

Eight healthy male participants were randomized in a controlled, single-blinded, crossover study. Each participant received a four-hour infusion of LAC and SAL in a randomized order. Assessor-blinded echocardiography and blood samples were performed. The primary endpoint was cardiac output (CO) measured by echocardiography.

Results

During LAC infusion, circulating lactate levels increased by 1.9 mmol/L (95% CI 1.8–2.0 mmol/L, P < 0.001) compared with SAL. CO increased by 1.0 L/min (95% CI 0.5–1.4 L/min, P < 0.001), driven primarily by a significant increase in stroke volume of 11 mL (95% CI 4–17 mL, P = 0.002), with no significant change in heart rate. Additionally, left ventricular ejection fraction improved by 5 percentage points (P < 0.001) and global longitudinal strain by 1.5 percentage points (P < 0.001). Preload indicators were elevated during SAL infusion compared with LAC infusion. Concomitantly, afterload parameters, including systemic vascular resistance and effective arterial elastance, were significantly decreased with LAC infusion compared with SAL, while mean arterial pressure remained similar. Indicators of contractility improved during LAC infusion.

Conclusions

In healthy participants, LAC infusion enhanced cardiac function, evidenced by increases in CO, stroke volume, and left ventricular ejection fraction compared with SAL. Indicators of contractility improved, afterload decreased, and preload remained stable. Therefore, LAC infusion may be an advantageous resuscitation fluid, particularly in patients with cardiac dysfunction.

 

Procedural sedative effect of remimazolam in ICU patients on invasive mechanical ventilation: a randomised, prospective study

Annals of Intensive Care volume 15, Article number: 8 (2025)

Published: 14 January 2025

Background

Invasive procedures and environmental factors in the intensive care unit (ICU) may cause anxiety and discomfort in patients, who often require sedation therapy. The aim of this study was to assess the safety of remimazolam tosilate for procedural sedation in ICU patients receiving mechanical ventilation following endotracheal intubation. Eighty patients from a single centre were randomly assigned to either the propofol group or the remimazolam group. Blood tests were conducted to evaluate changes in lactate, blood lipids, liver and kidney function, and inflammatory markers, and patients’ vital signs were observed over several periods. This study compared the incidence of delirium, the impact on liver and kidney function, circulatory effects, and changes in blood lipids between the two groups. These findings have optimised the selection of medications, providing ICU patients with more options for sedation therapy.

Methods

In this single-centre randomised controlled trial, intubated patients were randomly assigned to the remimazolam group or the propofol group. Under the same analgesic regimen, the two groups received remimazolam and propofol for procedural sedation.

Results

Our primary outcome was the mean arterial pressure (MAP), which significantly differed on Days 4 and 7 (P = 0.021, control group vs. experimental group = 85.23 ± 11.24 vs. 94.36 ± 13.18, P = 0.023, 83.55 ± 8.94 vs. 92.66 ± 7.02). With respect to liver and kidney function, the ∆AST value in the remimazolam group was significantly lower than that in the control group on Day 7 (P = 0.023). There were significant differences in triglyceride (TG) levels on Days 4 and 7 (P = 0.020) and in the ∆LDL on Day 7 (P = 0.027). Furthermore, the rates of dyslipidaemia and delirium in the remimazolam group were lower than those in the propofol group (85.0%, n = 40 vs. 90.0%, n = 40; 27.5%, n = 40 vs. 55%, n = 40).

Conclusion

Remimazolam is a novel benzodiazepine that has demonstrated promising applications in general anaesthesia and procedural sedation; however, its use in ICU sedation is still in the early stages of research. Current evidence suggests that remimazolam is a safe sedative that is particularly well suited for patients with haemodynamic instability. Large sample-size randomised clinical trials are warranted.

 

Creatinine production rate is an integrative indicator to monitor muscle status in critically ill patients

Critical Care volume 29, Article number: 23 (2025)

Published: 14 January 2025

Background

Both quantitative and qualitative aspects of muscle status significantly impact clinical outcomes in critically ill patients. Comprehensive monitoring of baseline muscle status and its changes is crucial for risk stratification and management optimization. However, repeatable and accessible indicators are lacking. We hypothesized that creatinine production rate (CPR) could serve as an integrative indicator of skeletal muscle status.

Methods

We conducted a series of animal and clinical studies. First, animal experiments were performed to determine whether CPR reflects not only muscle volume, but also qualitative muscle properties. We also evaluated the effects of acute systemic inflammation, a common feature of critical illness, on CPR, as well as its impact on muscle volume and metabolism. In clinical studies, we analyzed CPR, calculated based on urinary creatinine excretion and changes in serum creatinine, of critically ill patients. We assessed the factors affecting CPR on ICU admission and its temporal changes. Finally, we evaluated the clinical utility of CPR by examining the associations of the CPR index (CPR divided by height squared) on ICU admission and its changes with one-year survival.

Results

Animal studies revealed that CPR is determined by muscle volume, creatine content, and metabolic status. Systemic inflammation accompanied by muscle loss led to reduced CPR. Moreover, even without muscle loss, systemic inflammation decreased CPR, likely due to metabolic derangements. In ICU patients, CPR on admission strongly correlated with muscle cross-sectional area (CSA), with age and sex as additional significant factors. In contrast, the percent change in CPR showed a weak correlation with muscle CSA changes. Additionally, the acute-phase CPR trajectories did not show a consistent decline, suggesting multifactorial influences. In a cohort of 629 ICU patients, lower baseline CPR index (hazard ratio [HR] 1.125 per 0.1 g/day/m2 less, P < .001) and a decrease in CPR over the first three days (HR 1.028 per 5%, P = 0.032) were independently associated with higher one-year mortality.

Conclusions

CPR represents an integrative indicator of skeletal muscle status in critically ill patients, reflecting both quantitative and qualitative aspects. Monitoring CPR in the ICU may facilitate risk stratification and optimization of patient care.

 

 Understanding and addressing a ‘difficult’ family in ICU

Critical Care volume 29, Article number: 22 (2025)

Published: 13 January 2025

 

Abstract

Conflicts between ICU staff and patient/relatives are common and are a source of additional stress in an already tense environment. These conflicts vary from disagreements to serious controversies, which may lead to legal process or even violence. Unsuccessful communication is recognised as a common denominator for such disagreements. Both conflict prevention and conflict management/resolution rely on understanding and addressing the main reasons behind it. Using a case-example, we propose a ‘mentalisation-based’ approach to family meetings may improve communication and decrease conflict.

 

Double cycling with breath-stacking during partial support ventilation in ARDS: Just a feature of natural variability?

Critical Care volume 29, Article number: 19 (2025) 

Published: 10 January 2025

 

Background

Double cycling with breath-stacking (DC/BS) during controlled mechanical ventilation is considered potentially injurious, reflecting a high respiratory drive. During partial ventilatory support, its occurrence might be attributable to physiological variability of breathing patterns, reflecting the response of the mode without carrying specific risks.

Methods

This secondary analysis of a crossover study evaluated DC/BS events in hypoxemic patients resuming spontaneous breathing in cross-over under neurally adjusted ventilatory assist (NAVA), proportional assist ventilation (PAV +), and pressure support ventilation (PSV). DC/BS was defined as two inspiratory cycles with incomplete exhalation. Measurements included electrical impedance signal, airway pressure, esophageal and gastric pressures, and flow. Breathing variability, dynamic compliance (CLdyn), and end-expiratory lung impedance (EELI) were analyzed.

Results

Twenty patients under assisted breathing, with a median of 9 [5–14] days on mechanical ventilation, were included. DC/BS was attributed to either a single (42%) or two apparent consecutive inspiratory efforts (58%). The median [IQR] incidence of DC/BS was low: 0.6 [0.1–2.6] % in NAVA, 0.0 [0.0–0.4] % in PAV + , and 0.1 [0.0–0.4] % in PSV (p = 0.06). DC/BS events were associated with patient’s coefficient of variability for tidal volume (p = 0.014) and respiratory rate (p = 0.011). DC/BS breaths exhibited higher tidal volume, muscular pressure and regional stretch compared to regular breaths. Post-DC/BS cycles frequently exhibited improved EELI and CLdyn, with no evidence of expiratory muscle activation in 63% of cases.

Conclusions

DC/BS events during partial ventilatory support were infrequent and linked to breathing variability. Their frequency and physiological effects on lung compliance and EELI resemble spontaneous sighs and may not be considered a priori as harmful.

 

Development and external validation of a machine learning model for brain injury in pediatric patients on extracorporeal membrane oxygenation

Critical Care 29, Article number: 17 (2025)

Published: 09 January 2025

Background

Patients supported by extracorporeal membrane oxygenation (ECMO) are at a high risk of brain injury, contributing to significant morbidity and mortality. This study aimed to employ machine learning (ML) techniques to predict brain injury in pediatric patients ECMO and identify key variables for future research.

Methods

Data from pediatric patients undergoing ECMO were collected from the Chinese Society of Extracorporeal Life Support (CSECLS) registry database and local hospitals. Ten ML methods, including random forest, support vector machine, decision tree classifier, gradient boosting machine, extreme gradient boosting, light gradient boosting machine, Naive Bayes, neural networks, a generalized linear model, and AdaBoost, were employed to develop and validate the optimal predictive model based on accuracy and area under the curve (AUC). Patients were divided into retrospective cohort for model development and internal validation, and one cohort for external validation.

Results

A total of 1,633 patients supported by ECMO were included in the model development, of whom 181 experienced brain injury. In the external validation cohort, 30 of the 154 patients experienced brain injury. Fifteen features were selected for the model construction. Among the ML models tested, the random forest model achieved the best performance, with an AUC of 0.912 for internal validation and 0.807 for external validation.

Conclusion

The Random Forest model based on machine learning demonstrates high accuracy and robustness in predicting brain injury in pediatric patients supported by ECMO, with strong generalization capabilities and promising clinical applicability.

 

Ventilation distribution during spontaneous breathing trials predicts liberation from mechanical ventilation: the VISION study

Critical Care 29, Article number: 11(2025)

Published: 07 January 2025

Background

Predicting complete liberation from mechanical ventilation (MV) is still challenging. Electrical impedance tomography (EIT) offers a non-invasive measure of regional ventilation distribution and could bring additional information.

Research question.

Whether the display of regional ventilation distribution during a Spontaneous Breathing Trial (SBT) could help at predicting early and successful liberation from MV.

Study design and methods

Patients were monitored with EIT during the SBT. The tidal image was divided into ventral and dorsal regions and displayed simultaneously. We explored the ventral-to-dorsal ventilation difference in percentage, and its association with clinical outcomes. Liberation success was defined pragmatically as passing SBT followed by extubation within 24 h without reintubation for 7 days. Failure included use of rescue therapy, reintubation within 7 days, tracheostomy, and not being extubated within 24 h after succesful SBT. A training cohort was used for discovery, followed by a validation cohort.

Results

Among a total of 98 patients analyzed, 85 passed SBT (87%), but rapid liberation success occurred only in 40; 13.5% of extubated patients required reintubation. From the first minutes to the entire SBT duration, the absolute ventral-to-dorsal difference was consistently smaller in liberation success compared to all subgroups of failure (p < 0.0001). An absolute difference at 5 min of SBT > 20% was associated with failure of liberation, with sensitivity and specificity of 71% and 78% and positive predictive value 81% in a validation cohort.

Conclusion

During SBT, a large ventral-to-dorsal difference in ventilation indicated by EIT may help to rapidly identify patients at risk of liberation failure.

 

The impact of a tailored nutrition intervention delivered for the duration of hospitalisation on daily energy delivery for patients with critical illness (INTENT): a phase II randomised controlled trial

Critical Care 29, Article number: 8 (2025)

Published: 06 January 2025

Background

Nutrition interventions commenced in ICU and continued through to hospital discharge have not been definitively tested in critical care to date. To commence a program of research, we aimed to determine if a tailored nutrition intervention delivered for the duration of hospitalisation delivers more energy than usual care to patients initially admitted to the Intensive Care Unit (ICU).

Methods

A multicentre, unblinded, parallel-group, phase II trial was conducted in twenty-two hospitals in Australia and New Zealand. Adult patients, requiring invasive mechanical ventilation (MV) for 72–120 h within ICU, and receiving < 80% estimated energy requirements from enteral nutrition (EN) were included. The intervention (tailored nutrition) commenced in ICU and included EN and supplemental parenteral nutrition (PN), and EN, PN, and/or oral nutrition after liberation from MV, and was continued until hospital discharge or study day 28. The primary outcome was daily energy delivery from nutrition (kcal). Secondary outcomes included duration of hospital stay, ventilator free days at day 28 and total blood stream infection rate.

Main results

The modified intention to treat analysis included 237 patients (n = 119 intervention and n = 118 usual care). Baseline characteristics were balanced; the median [interquartile range] intervention period was 19 [14–35] and 19 [13–32] days in the tailored nutrition and usual care groups respectively. Energy delivery was 1796 ± 31 kcal/day (tailored nutrition) versus 1482 ± 32 kcal/day (usual care)—adjusted mean difference 271 kcal/day, 95% CI 189–354 kcal. No differences were observed in any secondary outcomes.

Conclusions

A tailored nutrition intervention commenced in the ICU and continued until hospital discharge achieved a significant increase in energy delivery over the duration of hospitalisation for patients initially admitted to the ICU.

Trial registration ClinicalTrials.gov Identifier NCT03292237. First registered 25th September 2017. Last updated 10th Feb 2023.