Critical Care Bulletin - May 2025

 

Endotoxin hemoadsorption in refractory septic shock with multiorgan dysfunction and extreme endotoxin activity

Critical Care volume 29, Article number: 206 Published: 20 May 2025

Abstract

Endotoxin septic shock is marked by severe organ failure and mortality rate that exceeds fifty percent, underscoring the critical need to tailor management strategies. Monitoring -endotoxin activity can guide the initiation and direction of adjunctive treatment for refractory septic shock through hemoadsorption. Thus, intervening based on the pathophysiological foundation may potentially improve outcomes. This represents a step towards precision medicine in the management of septic shock adjunctive therapies, addressing a knowledge gap in this pathology that remains insufficiently defined. Despite its potential, in the setting of refractory septic shock and multiorgan dysfunction with extreme endotoxin activity (EAA ≥ 0.9), the data about efficacy of endotoxin hemoadsorption is scarce.

 

Circular material flow of medication in the intensive care unit

Critical Care volume 29, Article number: 205 Published: 20 May 2025

Abstract

Background

Intensive care units (ICUs) contribute significantly to healthcare's environmental footprint, with medications playing a major role. This study performed a comprehensive Material Flow Analysis (MFA) of medications in a large academic ICU to quantify material flows and identify opportunities for sustainability.

Methods

A single-center MFA was conducted at a 50-bed ICU, analyzing all medications delivered in 2023. Medication and packaging components were weighed and categorized by active pharmaceutical ingredients (APIs), excipients, and packaging type. Total annual mass as well as daily medication and packaging waste per patient were calculated.

Results

The annual medication inflow totaled 234,337 kg, including 194,411 kg of medication content (5287 kg APIs, 189,124 kg excipients) and 39,923 kg of packaging. APIs constituted only 2.3% of the total medication mass. On average, patients received 89.5 medication units daily, totaling 5.0 kg of medication and generating 1.7 kg of packaging waste. Waste outflow comprised 194,413 kg to the sewage system, 21,894 kg for incineration, and 18,030 kg recycled, consisting primarily of continuous renal replacement therapy (CRRT) bags.

Conclusions

This MFA highlights significant opportunities to enhance ICU medication sustainability by targeting CRRT-related waste, optimizing fluid formulations to reduce excipient use, and minimizing packaging. These findings support the development of targeted interventions to reduce the environmental footprint of critical care.

 

Severe listeriosis in intensive care units: insights from a retrospective multicentric study

Critical Care volume 29, Article number: 201 Published: 19 May 2025

Background

Listeriosis is a rare but severe foodborne infection, particularly affecting immunocompromised individuals and older adults. Severe cases may lead to neurolisteriosis and sepsis, necessitating intensive care unit (ICU) admission. This study aims to analyze the demographic characteristics, clinical presentation, microbiological findings, treatments, and outcomes of critically ill patients with Listeria infections in the ICU.

Methods

A retrospective multicenter study was conducted across 23 French hospitals over a 10-year period, including ICU patients with culture-confirmed Listeria monocytogenes infections. Data on demographics, comorbidities, ICU admission characteristics, biological and microbiological parameters, treatments, and outcomes were collected. The primary outcome was ICU mortality. A multivariable logistic regression model was used to identify factors associated with mortality in patients with neurological manifestations.

Results

A total of 110 patients were included, with a median age of 68 years; 61% were male, and 71% were immunocompromised. Neurological involvement was present in most cases. Invasive mechanical ventilation was required in 58% of patients, and vasopressor support in 44%. ICU and in-hospital mortality rates were 25% and 32%, respectively. Among patients with neurolisteriosis, each 1-point decrease in Glasgow Coma Scale score at admission was associated with increased mortality (OR, 1.22; 95% CI 1.05–1.45; p = 0.009), as were higher cerebrospinal fluid (CSF) protein levels (OR, 1.56; 95% CI 1.15–2.41; p = 0.028). Steroid use was not significantly associated with reduced mortality (OR, 0.30; 95% CI 0.07–1.05; p = 0.076).

Conclusion

Listeriosis requiring ICU admission is associated with high morbidity and mortality, particularly in older and immunocompromised patients. The severity of these infections is reflected by the frequent need for organ support. Further research is needed to clarify the potential role of steroids in neurolisteriosis.

 

Identifying a unique signature of sepsis in patients with pre-existing cirrhosis

Critical Care volume 29, Article number: 199 Published: 19 May 2025

Background

The pre-existing diagnosis of cirrhosis is a complicating factor in the progression and prognosis of sepsis; however, the unique epidemiology, sepsis characteristics, and underlying mechanisms of immune dysregulation in sepsis among patients with cirrhosis remain incompletely understood. Our primary objective was to identify clinical outcomes and biological characteristics that differ between patients with and without cirrhosis among critically ill patients with sepsis.

Methods

We analyzed data from a prospective cohort of critically ill patients presenting to single center with sepsis. Subjects were followed for 6 days for the development of acute respiratory distress syndrome (ARDS) and acute kidney injury (AKI), and 30 days for mortality. Inflammatory, endothelial, and coagulopathic proteins were measured in plasma collected at ICU admission in a subset of patients. We determined associations of cirrhosis with outcomes using multivariable logistic regression adjusting for pre-specified confounders. We tested differences in plasma protein levels by cirrhosis diagnosis using the Wilcoxon Rank-sum test.

Results

We enrolled 2962 subjects, 371 (13%) of whom had a pre-existing diagnosis of cirrhosis. Patients with cirrhosis had higher severity of illness scores, were more likely to have an abdominal source of sepsis, and had more significant clinically measured coagulation abnormalities relative to patients without cirrhosis. In multivariate analysis, cirrhosis was associated with higher AKI risk (adjusted OR 1.65; 95% CI 1.21 to 2.26; P = 0.002), and 30-day mortality (adjusted OR 1.38; 95% CI 1.05 to 1.82; P = 0.022). There was no significant difference in risk for ARDS (adjusted OR 1.02; 95% CI 0.69 to 1.50; P = 0.92). Cirrhosis was associated with higher plasma levels of angiopoietin-2 (P < 0.001), von Willebrand factor (P < 0.001), and soluble thrombomodulin (P < 0.001), as well as lower levels of interleukin (IL)-10 (P < 0.001), IL-1β (P = 0.008), and IL-1RA (P = 0.036). There were no significant differences in levels of IL-6 (P = 0.30).

Conclusions

We identified associations between pre-existing cirrhosis and endothelial injury, AKI, and mortality in sepsis. Patients with pre-existing cirrhosis who develop sepsis may display a unique phenotype of endothelial dysfunction that requires unique targeted approaches.

 

Understanding and mitigating medication errors associated with patient harm in adult intensive care units: a scoping review

Intensive Care Medicine: Published 20 May 2025

Purpose

Medication interventions are fundamental to the care of the critically ill patient in the intensive care unit (ICU), relying on effective and appropriate delivery of the medication use process. Medication errors affect a high proportion of patients in the ICU. This scoping review maps the literature pertaining to medication errors and preventable adverse drug events in the adult ICU.

Methods

We searched seven electronic databases (PubMed, MEDLINE, EMBASE, CINAHL, Web of Science, Cochrane, Google Scholar), identifying 2960 records. After screening against predefined eligibility criteria, 48 records were included for data extraction.

Results

A high variation in incidence of medication errors and preventable adverse drug events were reported, reflecting the heterogeneity in study designs, surveillance methods and preventability assessments. Associated risks factors include patient (high severity of illness, older age), clinical (renal dysfunction, prolonged ICU stay), staff (staff inexperience, role overload), environmental (interruptions, transfer of care) in addition to high-risk medications. The rate of serious or life-threatening harm was low at 1–5% of all medication errors. Half (n = 11, 55%) of the interventions or mitigation practices were focused on the medication prescription phase.

Conclusion

Most medication errors in ICU are identified and intercepted by systems and staff. A minority lead to preventable patient harm and increased length of stay. Decision support embedded in e-prescribing systems, medication reconciliation and review processes and clinical pharmacist activities reduce medication errors and patient harm.

 

 

Individualized mean arterial pressure targets in critically ill patients guided by non-invasive cerebral-autoregulation: a scoping review

Critical Care volume 29, Article number: 196 Published: 16 May 2025

Background

Current guidelines recommend a uniform mean arterial pressure (MAP) target for resuscitating critically ill patients; for example, 65 mmHg for patients with sepsis and post-cardiac arrest. However, since cerebral autoregulation capacity likely varies widely in patients, uniform target may be insufficient in maintaining cerebral perfusion. Personalized MAP targets, based on a non-invasive determination of cerebral autoregulation, may optimize perfusion and reduce complications.

Objectives

This scoping review summarizes the numerical values, feasibility, and clinical data on personalized MAP targets in critically ill patients. The focus is on non-invasive monitoring, such as near-infrared spectroscopy and transcranial doppler ultrasound, due to their safety, practicality and applicability to patients with- and without brain injury.

Methods

Following PRISMA-ScR guidelines, a systematic search of Ovid MedLine, Embase (Ovid), and the Cochrane Library (Wiley) was conducted on September 28, 2023. Two independent reviewers screened titles, abstracts, and full texts for eligibility and manually reviewed references.

Results

Of 7,738 studies were identified, 49 met the inclusion criteria. Of these, 45 (92%) were observational and 4 (8%) were interventional. Patient populations included cardiac surgery (26, 53%), non-cardiac major surgery (4, 8%), cardiac arrest (8, 16%), brain injury (7, 14%), respiratory failure and shock (3, 6%), and sepsis (3, 6%). Optimal MAP was reported in 24 (49%), lower limit of autoregulation in 23 (47%), and upper limit of autoregulation in 10 studies (20%). Thirty-four studies reported partial data loss due to software failures, anomalous data, insufficient natural MAP fluctuation, and workflow barriers. Available randomized controlled trials (RCT) identified challenges with maintaining patients within their target range. Studies explored the associations between personalized MAP targets and a wide range of neurological and non-neurological outcomes, with the most significant and consistent associations identified for acute kidney injury and major morbidity and mortality. Ten studies investigated demographic predictors identifying only few predictors of personalized targets.

Conclusion

Preliminary investigations suggest considerable variability in personalized MAP targets, which may explain differences in clinical outcomes among critically ill populations. Key gaps remain, including a lack of observational studies in critically ill subpopulations other than cardiac surgery and well-designed RCTs. Resolving identified feasibility barriers might be crucial to successfully carrying out future studies.

 

Optimum electrical impedance tomography-based PEEP and recruitment-to-inflation ratio in patients with severe ARDS on venovenous ECMO

Critical Care volume 29, Article number: 195 Published: 16 May 2025

Rationale

The significance of the Recruitment to Inflation (R/I) ratio in identifying PEEP recruiters in patients undergoing ultra-protective lung ventilation during venovenous ECMO is not well established.

Objectives

To compare the concordance of the R/I ratio and Electrical Impedance Tomography (EIT) in determining optimum PEEP settings in severe ARDS patients on ECMO and ventilated with very low tidal volumes.

Methods

Initially, a low-flow insufflation was performed to detect and measure the airway opening pressure (AOP). Subsequently, the R/I ratio was calculated from PEEP 15–5 cmH₂O, followed by a decremental PEEP trial (20–6 cmH₂O in 2 cmH₂O steps) monitored by EIT. The optimum EIT-based PEEP was defined as the intersection of the collapse and overdistension curves.

Main results

Among 54 ECMO patients (tidal volume: 4.8 [3.0–6.0] mL/kg), 13 (24%) exhibited an airway opening pressure (AOP) of 11 (8–14) cmH₂O. The cohort’s median R/I ratio was 0.43 (0.28–0.61). A tertile-based analysis of the R/I ratio (≤ 0.34; 0.34–0.54; > 0.54) revealed median optimum EIT-based PEEP of 8 [8–10], 10 [8–14], and 14 [12–16] cmH₂O, respectively. The R/I ratio demonstrated weak inverse correlations with lung overdistension (R² = 0.19) and positive correlations with lung collapse (R² = 0.26) measured by EIT (p < 0.01).

Conclusion

The R/I ratio is feasible during ultra-protective ventilation and provides valuable indications for guiding PEEP titration. Specifically, an R/I ratio > 0.34 may help identify patients likely to benefit from further individualized PEEP optimization using EIT. In contrast, when the R/I ratio is ≤ 0.34, a moderate PEEP level (8–10 cmH₂O) may suffice.

 

High flow nasal therapy versus noninvasive ventilation for AECOPD with acute hypercapnic respiratory failure: a meta-analysis of randomized controlled trials

Annals of Intensive Care volume 15, Article number: 64 Published: 14 May 2025

Background

Guidelines recommend the use of noninvasive ventilation (NIV) and high-flow nasal cannula (HFNC) in patients with chronic obstructive pulmonary disease (COPD) and hypercapnic acute respiratory failure (ARF). It is unclear whether HFNC is noninferior to NIV in terms of the rate of tracheal intubation or mortality. This meta-analysis aimed to compare the efficacy of HFNC and NIV in patients with AECOPD and hypercapnic ARF.

Methods

A systematic search was made of PubMed, Embase, Cochrane Library, and clinicaltrials.gov, without language restrictions. Randomized controlled trials (RCTs) on treatment of hypercapnic AECOPD with HFNC, compared with NIV, were reviewed. Estimated effects of included studies were pooled as risk ratios (RRs), with 95% confidence intervals (CIs).

Results

Four RCTs (enrolling 486 patients) met the inclusion criteria. There was no statistically significant difference in all-cause mortality (RR 0.97, 95% CI 0.56 to 1.68), and intubation rate (RR 1.67, 95% CI 0.99 to 2.83) between the two groups. The treatment switch rate (RR 2.60, 95% CI 1.54 to 4.38) and treatment failure rate (RR 1.64, 95% CI 1.04 to 2.60) were significantly lower in NIV groups.

Conclusions

Compared with NIV, HFNC was not associated with increased mortality and intubation rate. More patients receiving HFNC oxygen therapy experienced treatment failure and switched to NIV, which may mask the fact that HFNC is inferior to NIV in patients with AECOPD and hypercapnic ARF.

 

Frailty and Long-Term Survival in Patients With Critical Illness After Nonhome Discharge: A Retrospective Cohort Study

Critical Care Medicine : April 29, 2025.

Importance: 

Patients with frailty are more frequently discharged to rehabilitation or residential aged care facility (RACF), defined as nonhome discharge, than those without frailty. An increase in nonhome discharge is considered to be one of the collateral “costs” associated with declining hospital mortality. However, it is unclear whether this association applies to patients with frailty, particularly in the long term.

Objectives: 

To determine the impact of frailty on long-term survival in patients who had a nonhome discharge following an ICU admission.

Design: 

A retrospective multicenter cohort study.

Setting and Participants: 

All medical patients (≥ 16 yr old) admitted to Australian and Zealand ICUs, with a documented Clinical Frailty Scale (CFS) and a nonhome discharge from January 1, 2018, to March 31, 2022, were included.

Interventions: 

None.

Measurements and Main Results: 

Primary outcome was survival time up to 4 years. We used Cox proportional hazards regression models with robust sandwich variance estimators to assess the effect of frailty (defined as CFS = 5–8) on survival time after ICU admission between groups. We also analyzed the effect of frailty on long-term survival based on their age and nonhome discharge location. Of the 57,652 patients, 17,383 (30.2%) were frail. Overall 4-year survival was lower in patients with frailty than those without (32.5% vs. 64.3%; p < 0.001). Frailty was associated with shorter survival times (adjusted hazard ratio [aHR], 1.50; 95% CI, 1.43–1.57). Frailty was associated with a greater reduction in survival in patients younger than 65 years old (aHR, 1.73; 95% CI, 1.59–1.88), 65–80 years (aHR, 1.47; 95% CI, 1.38–1.57), or older than 80 years (aHR, 1.35; 95% CI, 1.26–1.45). Frailty was associated with greater reduction in survival in those discharged to rehabilitation (aHR, 1.52; 95% CI, 1.39–1.65) or acute hospitals (aHR, 1.56; 95% CI, 1.48–1.65) than those discharged to RACF (aHR, 0.94; 95% CI, 0.83–1.06).

Conclusions: 

Frailty was independently associated with shorter time to death following a nonhome discharge after an ICU admission.

Relevance: 

There was an independent association between patients with frailty admitted to ICU and had a nonhome discharge with the shorter time to death than those without frailty.

 

 

 

Peri-intubation complications in critically ill obese patients: a secondary analysis of the international INTUBE cohort

Critical Care volume 29, Article number: 192 Published: 13 May 2025

Abstract

Background

Airway management in critically ill obese patients is potentially associated with a higher risk of adverse events due to a constellation of physiological and anatomical challenges. Data from international prospective studies on peri-intubation adverse events in obese critically ill patients are lacking.

Methods

INTUBE (International Observational Study to Understand the Impact and Best Practices of Airway Management In Critically Ill Patients) was an international multicentre prospective cohort study enrolling critically ill adult patients undergoing in-hospital tracheal intubation in 197 sites from 29 countries worldwide from October 1, 2018, to July 31, 2019. This secondary analysis compares airway management practices and outcomes between obese (body mass index–BMI ≥ 30 kg/m²) and non-obese patients (BMI < 30 kg/m²).

Results

A total of 2946 patients met inclusion criteria for this secondary analysis, 639 (21.7%) obese and 2307 (78.3%) non-obese. Severe peri-intubation hypoxemia was more frequently reported in obese compared to non-obese patients (12.1% vs 8.6% respectively, p = 0.01). Variables independently associated with a higher risk of peri-intubation hypoxemia were baseline SpO₂/FiO₂ (OR 0.996, 95% CI 0.994–0.997), 30–45° head-up position (OR 1.53, 95% CI 1.04–2.26) and first-pass intubation failure (OR for first-pass success 0.21, 95% CI 0.15–0.29). Obesity (OR 0.71, 95% CI 0.56–0.91) and 20° head-up position (OR 0.67, 95% CI 0.47–0.95) were independently associated with higher likelihood of first-pass intubation failure. In contrast, intubation by staff physician/consultant (OR 1.70, 95% CI 1.30–2.21) or anesthesiologists (OR 1.98, 95% CI 1.55–2.53) were associated with higher first-pass success.

Conclusions

Compared to non-obese patients, obese critically ill exhibit a higher incidence of peri-intubation severe hypoxemia. In this population, worse baseline oxygenation and first-pass intubation failure significantly increase the risk of peri-intubation severe hypoxemia. As obesity is linked to a higher likelihood of first-pass intubation failure, likely driven by more challenging airway features, in this high-risk population first attempt should be performed by an expert operator to minimize peri-intubation complications.

 

ESICM—ESPNIC international expert consensus on quantitative lung ultrasound in intensive care

Intensive Care Medicine Published: 12 May 2025

Purpose

To provide an international expert consensus on technical aspects and clinical applications of quantitative lung ultrasound in adult, paediatric and neonatal intensive care.

Methods

The European Society of Intensive Care (ESICM) and the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) endorsed the project. We selected an international panel of 20 adult, paediatric and neonatal intensive care experts with clinical and research expertise in quantitative lung ultrasound, plus two non-voting methodologists. Fourteen clinical questions were proposed by the chairs to the panel, who voted for their priority (1–9 Likert-type scale) and proposed modifications/supplementing (two-round vote). All the questions achieved the predefined threshold (mean score > 5) and 14 groups of 3 mixed adult/paediatric experts were identified to develop the statements for each clinical question; predefined groups of experts in the fields of adult and paediatric/neonatal intensive care voted statements specific for these subgroups. An iterative approach was used to obtain the final consensus statements (two-round vote, 1–9 Likert-type scale); statements were classified as with agreement (range 7–9), uncertainty (4–6), disagreement (1–3) when the median score and ≥ 75% of votes laid within a specific range.

Results

A total of 46 statements were produced (4 adults-only, 4 paediatric/neonatal-only, 38 interdisciplinary); all obtained agreement. This result was also achieved by acknowledging in the statements the current limitations of quantitative lung ultrasound.

Conclusion

This consensus guides the use of quantitative lung ultrasound in adult, paediatric and neonatal intensive care and helps identify the fields where further research will be needed in the future.

 

Physiological comparison of noninvasive ventilation and high-flow nasal oxygen on inspiratory efforts and tidal volumes after extubation: a randomized crossover trial

Critical Care volume 29, Article number: 185 Published: 08 May 2025

Background

Extubation failure leading to reintubation is associated with high mortality. In patients at high-risk of extubation failure, clinical practice guidelines recommend prophylactic non-invasive ventilation (NIV) over high-flow nasal oxygen (HFNO) immediately after extubation. However, the physiological effects supporting the beneficial effect of NIV have been poorly explored. We hypothesized that NIV may reduce patient inspiratory efforts to a greater extent than HFNO after extubation.

Methods

In a prospective physiological study, patients at high-risk of extubation failure (> 65 years old or underlying cardiac or respiratory disease) were included to receive after planned extubation prophylactic NIV and HFNO in a randomized crossover order, followed by standard oxygen. Inspiratory efforts were assessed by calculation of the simplified esophageal pressure–time-product per minute (sPTP_es in cmH₂O s/min). Tidal volumes, distribution and homogeneity of ventilation were estimated using electrical impedance tomography.

Results

Twenty patients were retained in the analysis. Inspiratory efforts were lower with NIV than with HFNO (sPTP_es 196 cm H₂O s/min [116–234] vs. 220 [178–327], p < 0.001) whereas tidal volumes were larger with NIV than with HFNO (8.4 mL/kg of predicted body weight [6.7–9.9] vs. 6.9 [5.3–8.6], p = 0.005). There was a non-significant increase in dorsal region ventilation under NIV compared to HFNO.

Conclusions

In patients at high-risk of extubation failure, prophylactic NIV significantly decreased inspiratory efforts with increased tidal volumes compared to HFNO. The clinical benefits of NIV to prevent reintubation in patients at high-risk may be mediated by these physiological effects.

 

Incidence and Associated Risk Factors for Falls in Adults Following Critical Illness: An Observational Study

Critical Care Medicine : April 18, 2025.

Objective: 

To explore the incidence of falls and associated risk factors in the first year after hospital discharge in survivors of critical illness.

Design: 

Prospective single-site observational study.

Setting: 

University-affiliated mixed ICU.

Patients: 

One hundred ICU adults who required invasive ventilation for 48 hours and in an ICU for at least 4 days.

Interventions: 

Not applicable.

Measurements and Main Results: 

Falls were monitored prospectively for 1 year with completion of monthly falls calendars. Falls data included the number of people who had falls/no falls/recurrent falls, falls rate per person per year, and time to first fall. Fall severity was classified according to the Schwenck classification scheme to examine injurious falls requiring medical intervention. Other outcomes considered included assessments of balance, strength, function, cognition, psychologic health, and health-related quality of life. One hundred participants (31% female) were recruited with a mean age of 58.3 ± 16.2 years, and a median ventilation duration of 6.3 days [4.0–9.1]. Sixty-one percent fell at least once in the first year with the majority sustaining two or more falls (81.4%) and one in four sustained an injurious fall requiring medical attention. The falls incidence rate was 4.4 falls per person-year (95% CI, 3.2–5.9), with the highest incidence occurring less than 3 months after hospital discharge (5.9 falls/person-year [95% CI, 4.4–7.8]). Time to first fall or injurious fall was 36 [11–66] and 95 (95% CI, 40–155) days, respectively. Key risk factors for falls at the time of hospital discharge include comorbidities, higher discharge medications, balance, and muscle strength.

Conclusions: 

There was a high falls incidence in ICU survivors. The study findings suggest a critical window may exist within the first 3 months after hospital discharge and the need for screening, pharmacological optimization, and exercise training in this patient group.

 

Depression or anxiety and long-term mortality among adult survivors of intensive care unit: a population-based cohort study

Critical Care volume 29, Article number: 179 (2025) Published: 06 May 2025

Background

Many patients who survive intensive care unit (ICU) stays experience persistent mental impairments. It is estimated that one-third of ICU survivors suffer from psychiatric disorders. However, research into how these disorders affect long-term outcomes in this population is scarce. Therefore, the aim of this study is to investigate the association between depression or anxiety and long-term mortality among ICU survivors.

Methods

This population-based cohort study included patients admitted to the ICU between January 1, 2015 and December 31, 2019, who survived at least 1 year after ICU discharge. Exclusions were made for patients admitted for non-medical reasons and those who had been in the ICU in the previous 2 years, and 799,645 patients were included in the study. Follow-up data were obtained for up to 7 years. The primary outcome was long-term cumulative mortality. Mortality rates for patients with and without diagnoses of depression or anxiety were compared.

Results

Of the 799,645 adult ICU survivors, 98,530 (12.3%) were newly diagnosed with depression or anxiety post-discharge, and 265,092 (33.2%) had been diagnosed prior to ICU admission. Multivariate Cox proportional hazards regression analysis revealed that the adjusted hazard ratio (HR) for long-term mortality was 1.17 (95% CI, 1.16–1.19) for those newly diagnosed with depression or anxiety, 1.28 (95% CI, 1.26–1.30) for depression alone, and 1.08 (95% CI, 1.06–1.11) for anxiety alone. For those with prior diagnoses, the adjusted HR was 1.08 (95% CI, 1.07–1.09) overall, 1.12 (95% CI, 1.11–1.14) for depression, and 1.04 (95% CI, 1.03–1.05) for anxiety.

Conclusions

ICU survivors newly diagnosed with depression or anxiety exhibit higher long-term mortality rates compared to those without such diagnoses, including those diagnosed before ICU admission. Particularly, newly diagnosed depression is associated with an elevated mortality rate. These findings underscore the need for psychological interventions to enhance long-term survival among ICU survivors.

 

 

Association of low-dose ketamine with hallucinations in critically ill patients: a target trial emulation

Intensive Care Medicine: Published 05 May 2025

Purpose

Ketamine use is a potentially modifiable risk factor for hallucinations. We aimed to use target trial emulation to investigate the association between low-dose ketamine and development of hallucinations in critically ill patients in the intensive care unit (ICU).

Methods

Retrospective study using data from a university affiliated ICU in Melbourne, Australia. Application of marginal structural models and parametric g-formulas to assess the impact of low-dose ketamine on the development of hallucinations.

Results

We studied 7514 patients from June 2016 to April 2021. Of these, 625 patients (8%) received low-dose ketamine, beginning at a median of 0 (0–1) days from ICU admission and at a mean daily dose of 0.11 (0.08–0.15) mg/kg/h. Low-dose ketamine treated patients had a higher rate of hallucinations within 30 days of ICU admission (26% vs. 7%; p < 0.001) and the first episode of hallucination occurred earlier than in unexposed patient (2 [1–3] vs. 3 [1–7] days from ICU admission; p < 0.001). After adjustment for baseline and time-dependent confounders, low-dose ketamine was associated with a higher risk of hallucinations within 30 days (OR, 6.46 [95% CI 5.17–8.07]; p < 0.001). These findings were confirmed with parametric g-formulas.

Conclusions

In ICU patients, low-dose ketamine was strongly associated with an increased risk of hallucinations. However, these findings should be interpreted with caution due to the observational nature of the study and the risk of residual confounding.

 

Maintaining ventilation with very low tidal volume and positive-end expiratory pressure versus no ventilation during cardiopulmonary bypass for cardiac surgery in adults: a randomized clinical trial

Intensive Care Medicine: Published 05 May 2025

Purpose

Cardiopulmonary bypass (CPB) during cardiac surgery mechanically circulates and oxygenates the blood, bypassing the heart and lungs. Despite limited evidence, maintaining mechanical ventilation (MV) during CPB is recommended, as ventilator strategies during surgery may reduce the occurrence of postoperative infections. We aimed to determine whether maintaining MV for cardiac surgery would decrease postoperative infections compared with stopping MV during CPB.

Methods

We conducted a multicenter, single-blind, randomized trial among adult patients undergoing scheduled cardiac surgery with CPB in six hospitals in France. During CPB, the tracheal tube was disconnected from the ventilator in the control group (MV- group). In the MV + group, ventilation was maintained during CPB with very low tidal volume ventilation, using a tidal volume of 2.5 mL/kg of predicted body weight, with 5–7 cmH₂O positive end expiratory pressure. The primary outcome was the occurrence of all types of postoperative infections within the first 28 days after surgery. There were six secondary evaluation criteria including the number of days of exposure to antibiotics.

Results

A total of 1362 patients were enrolled in the study. Postoperative infection occurred in 74 out of 680 patients (10.9%) in the MV− group, compared to 68 out of 682 patients (10.0%) in the MV + group (relative risk, 0.92; 95% confidence interval [CI] 0.67–1.25; p = 0.58). Antibiotic use was higher in the MV + group than in the MV- group (incidence risk ratio, 1.08; 95% CI 1.02–1.15; p = 0.02). There were no significant differences between the groups for all other secondary outcomes or for the incidence of adverse events.

Conclusions

Maintaining very low tidal volume ventilation with positive end-expiratory pressure during CPB did not reduce postoperative infections at 28 days compared to when mechanical ventilation was stopped during CPB. An unexpectedly higher use of antibiotics was observed when ventilation was maintained.