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.