High-flow nasal cannula oxygen during breaks from noninvasive ventilation after extubation: an observational study

Intensive Care Medicine: Published: 13 July 2026

Abstract

Purpose

Clinical practice guidelines recommend prophylactic noninvasive ventilation (NIV) after extubation in high-risk patients. The effects of high-flow nasal cannula (HFNC) oxygen during breaks from NIV after extubation have been poorly explored. Our objective was to assess whether HFNC rather than standard oxygen during breaks from NIV may prevent extubation failure.

Methods

Observational study based on two multicenter clinical trials including patients at high-risk of extubation failure (> 65 years or with underlying cardiac or respiratory disease). We included the 1077 patients who received prophylactic NIV after extubation, alternating with HFNC (NIV/HFNC) or standard oxygen (NIV/O₂). The primary outcome was the proportion of patients who failed extubation (reintubation or death within the seven days following extubation). We used G-computation to estimate the causal effect of HFNC on the risk of extubation failure, while accounting for confounding factors.

Results

After extubation, 655 patients (61%) received NIV/HFNC while 422 (39%) received NIV/O₂. The extubation failure rate at day 7 was significantly lower with NIV/HFNC than with NIV/O₂ (13.7% vs. 18.5%; difference, − 4.7% [95% CI, − 9.4% to – 0.3%]; p = 0.036). Using G-computation, NIV/HFNC was not more effective than NIV/O₂ in reducing the risk of extubation failure, with an estimated adjusted difference of − 3.9% [95% CI, − 8.7% to 0.9%]. Reintubation rates were significantly lower with NIV/HFNC than with NIV/O₂ at 48h, but did not significantly differ beyond 48h.

Conclusions

Although the adjusted analysis did not confirm the favorable unadjusted findings, HFNC during breaks from NIV might decrease the risk of extubation failure, and warrants future clinical trials.

Critical Care Bulletin: May 2026

 

Effects of out-of-bed armchair positioning on oxygenation in spontaneously breathing ICU patients receiving respiratory support: a randomized controlled trial

Intensive Care Medicine: Published: 18 May 2026

Purpose

Comparing the effects of an out-of-bed armchair position versus an in-bed semi-recumbent position on oxygenation in spontaneously breathing intensive care unit (ICU) patients, receiving respiratory support is a common practice with limited supported evidence.

Methods

A single-center randomized controlled trial in spontaneously breathing adult ICU patients receiving invasive pressure support ventilation, high-flow nasal oxygen, or non-invasive ventilation. Patients were assigned to armchair or semi-recumbent in-bed positioning for 3 h. Arterial blood gasses were obtained immediately before and after positioning. PaO₂/FiO₂ (P/F) changes were analyzed with a linear mixed-effects model including group, time, and their interaction, adjusted for stratification variables.

Results

284 patients were randomized (146 and 138 in the armchair and bed groups, respectively). Baseline P/F ratios did not differ between groups. A significant interaction between group and time was observed (p = 0.002). In the armchair group, the P/F ratio increased by 13 mm Hg (95% CI 1–24), whereas it decreased by 13 mm Hg (95% CI − 25 to − 1) in the bed group. The post-positioning marginal mean P/F ratio was higher in the armchair group (241 mm Hg, 95% CI 214–268) than in the bed group (206 mm Hg, 95% CI 179–233; p = 0.004). No serious adverse events occurred. Minor adverse events were more frequent in the armchair group but had minimal impact on positioning duration.

Conclusion

In spontaneously breathing ICU patients receiving respiratory support, out-of-bed armchair positioning was associated with higher oxygenation after 3 h than remaining in a semi-recumbent position, with no serious adverse events observed.

 

 

Airway management in critically ill patients with obesity

Intensive Care Medicine: Published: 13 May 2026

Abstract

Obesity is a global health challenge. An increasing number of patients with obesity are admitted to an intensive care unit. Airway management in these patients represents a unique challenge due to significant anatomical and physiological alterations. Increased adipose tissue in the face, cheeks, pharynx, hypopharynx, and neck narrows the upper airway, renders soft tissues more collapsible, and complicates airway management. In addition, the functional residual capacity is reduced, resulting in markedly shortened safe apnea time, contributing to severe hypoxemia during intubation. Non-invasive ventilation is effective in mitigating this risk and should be applied from pre-induction to laryngoscopy. Peri-intubation physiological optimization should include assessment of preload and cardiac contractility, with careful consideration of right ventricular strain. The transition from negative to positive intrathoracic pressure should be closely monitored, with cautious titration of positive end-expiratory pressure. Recognition of these anatomical and physiological challenges may prompt clinicians to consider awake intubation in selected patients. When rapid sequence induction is performed, both ketamine and etomidate are appropriate options; the choice between them should be guided by the clinical context, patient characteristics, local practice patterns and availability. Videolaryngoscopy increases the incidence of successful intubation on the first attempt and should be adopted routinely in the population with obesity. Several questions remain unanswered, including the safety and efficacy of pre-emptive vasopressor use to prevent post-intubation cardiovascular collapse and the optimal dosing of hypnotic agents to achieve ideal intubation conditions, while minimizing adverse events.

 

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.

 

Potential therapeutic benefit of exogenous ketone ester administration in delirium: a narrative review

Critical Care volume 29, Article number: 424 (2025) Published: 07 October 2025

Abstract

Delirium is a prevalent neuropsychiatric syndrome during critical illness and is associated with prolonged hospitalization, increased mortality, and post-ICU cognitive decline. It is hypothesized to result from systemic inflammation, disrupted neurotransmission, and failure of cerebral energy metabolism. This narrative review highlights the key role of altered neurometabolism and neuroinflammation, which occurs due to peripheral inflammation, compromised blood-brain barrier integrity, and increased microglial glycolysis. These changes limit neuronal glucose uptake, leading to a brain energy crisis and consequently amplifying oxidative and inflammatory stress. We focus on studies of ICU delirium in the setting of acute critical illness with an emphasis on sepsis-associated encephalopathy, where mechanistic data derived from murine models are most robust. Ketones bypass the glycolytic bottleneck and enter the tricarboxylic acid cycle directly, activating signaling pathways that enhance mitochondrial biogenesis, bolster antioxidant defenses, modulate neurotransmission, and reduce inflammation. In models of neurodegenerative diseases and traumatic brain injury, ketosis restores cerebral metabolism, reduces neuroinflammation, and enhances cognitive function. Additionally, preliminary human studies have demonstrated cognitive benefits and patient tolerance of ketone supplementation. Although data in the critically ill are limited, pilot studies suggest that enteral ketone supplementation can safely achieve therapeutic serum concentrations without worsening acidosis or hemodynamic instability. We hypothesize that exogenous ketone ester supplementation may support brain energy production by providing an alternative substrate for energy production, reducing microglial substrate competition, and mitigating the neuronal stress that precipitates delirium. In conclusion, exogenous ketone esters are a biologically plausible, rapidly acting metabolic intervention that warrants rigorous clinical evaluation as a novel strategy to prevent or treat delirium in those who are critically ill. However, randomized controlled trials are essential for verifying safety, determining optimal dosing, and assessing clinical effectiveness in the intensive care setting.

 

Determinants of ICU memories and the impact on the development and trajectory of post-traumatic stress symptoms: a multicenter longitudinal cohort study

Intensive Care Medicine Published: 06 October 2025

 Purpose

To identify demographic and clinical determinants of memory formation in intensive care unit (ICU) patients, and determine the relationship between ICU memories and the development and trajectory of post-traumatic stress disorder (PTSD) symptoms.

Methods

Adult patients (n = 426) from two Dutch University ICUs underwent a structured telephone interview using the validated ICU-Memory Tool (ICU-MT) 3 months post-ICU and were assessed for symptoms of PTSD using the Impact of Event Scale (IES-6) at 3 and 12 months post-ICU.

Results

Factual memories without delusional memories were present in 47.7% (n = 203), complete ICU amnesia in 13.8% (n = 59), and delusional memories in 38.5% (n = 164) of patients. Delirium was present in 41% (n = 68) of patients with delusional memories. Using multinomial logistic regression, female sex and number of days with deep sedation were associated with ICU amnesia (aOR 1.99, 95% CI 1.04–3.81, and aOR 1.34, 95% CI 1.09–1.65, respectively), whereas delirium and length of ICU stay were associated with delusional memories (aOR 1.94, 95% CI 1.04–3.61, and aOR 1.11, 95% CI 1.02–1.21, respectively). Of 250 patients assessed at both time points, the prevalence of PTSD symptoms increased significantly over time (4.5 to 10.0%, p < 0.01), driven by a significant increase among those with delusional memories (6.7 to 18.1%, p < 0.01). In a linear mixed-effects model, delusional memories were independently linked to both 3- and 12-month symptoms of PTSD (vs. factuals, adjusted %-difference in mean IES score, 12.9%, 95% CI 2.6–24.1%, and 18.1%, 95% CI 5.2–32.5%, respectively).

Conclusions

Female sex and prolonged deep sedation were associated with complete ICU amnesia, whereas a longer ICU stay and delirium were associated with delusional memories, although these memories were also common in those without delirium. Delusional memories were independently linked to the development and persistence of PTSD symptoms. Targeted interventions to mitigate memory disturbances, both during and after the ICU, may help alleviate the psychological impact of critical illness.

 

Critical Care Bulletin: August 2025

 

Immunosuppressive therapy management during sepsis in kidney transplant recipients: a prospective multicenter study

Annals of Intensive Care volume 15, Article number: 116, Published: 10 August 2025

Background

Sepsis is the leading cause of Intensive Care Unit (ICU) admissions in kidney transplant recipients (KTRs). However, the optimal immunosuppressive therapy (IST) management in this context is not well-defined. We aimed to evaluate the impact of IST management in the ICU on mortality rates and kidney graft function 6 months after inclusion in KTRs admitted for sepsis.

Methods

We conducted a multicenter, prospective, observational study over 1 year in 11 French ICUs. Inclusion criteria were all KTRs who have been transplanted for at least 3 months, admitted to the ICU for sepsis. All changes of IST (7 days prior to ICU admission or throughout the ICU stay) were collected. The primary outcome was MAKE 180 (Major Adverse Kidney Event), a composite outcome including mortality, kidney graft dysfunction and dialysis requirement at 180 days after inclusion.

Results

One hundred and twenty-four patients were included. The main cause of ICU admission was respiratory failure for 78 patients (62.9%). Predominant IST management was mycophenolic acid (MPA) discontinuation for 74 patients (59.7%) and calcineurin inhibitor (CNI) continuation for 63 patients (50.8%). By multivariable analysis, after adjustment for age, non-renal SOFA score at admission, kidney function at admission, sex, and history of cellular rejection we did not find any significant association between MAKE 180 and CNI discontinuation (adjusted OR = 1.05, 95% CI 0.87–1.26, p = 0.6). In contrast, MPA discontinuation was significantly associated with MAKE 180 (adjusted OR = 1.45, 95% CI 1.07–1.96, p = 0.018). No significant association was found between IST discontinuation and ICU-acquired infections (adjusted OR = 1.14, 95% CI 0.95–1.36, p = 0.157). Among ICU survivors, only 2 graft rejections occurred during the year following ICU discharge.

Conclusion

This study is the first prospective investigation to suggest an association between MPA discontinuation and adverse outcomes during sepsis in critically-ill KTRs. These findings must be interpreted with caution given the potential confounding introduced by SARS-Cov-2–specific treatment protocols. Further interventional trials are necessary to optimize immunosuppressive drug strategies in KTRs during sepsis.

 

Candida auris infections in ICU patients: risk factors, outcomes, and antifungal resistance patterns

Critical Care volume 29, Article number: 332, Published: 28 July 2025

Background

Candida auris has emerged as a major nosocomial pathogen in intensive care units worldwide due to its multidrug resistance, environmental persistence, and high transmission potential. While several outbreak reports exist, there remains limited comparative data on clinical features, resistance profiles, and outcomes between Candida auris and non-auris Candida candidemia, particularly in Indian ICU settings. This study aimed to evaluate the incidence, risk factors, antifungal resistance, and clinical outcomes of Candida auris bloodstream infections in comparison to non-auris Candida infections among ICU patients.

Methods

This retrospective cohort study was conducted over four years (January 2020–December 2023) in the ICU of a tertiary care hospital in eastern India. Adult patients (≥ 18 years) with culture-confirmed candidemia were included and stratified into Candida auris and non-auris groups. Demographic, clinical, therapeutic, and microbiological data were extracted. Antifungal susceptibility testing was performed as per CLSI and CDC guidelines. Multivariate logistic regression identified risk factors associated with Candida auris infection. Survival analysis were compared using Kaplan–Meier and Cox regression analysis.

Results

Of 267 ICU patients with candidemia, 38 (14.2%) had Candida auris infection. Candida auris patients were older (median age 60 vs. 53 years) and had lower SOFA scores at admission (median 7 vs. 8; p = 0.02). On multivariate analysis, increasing age (OR 1.10, p = 0.0003) and female sex (OR 16.35, p = 0.012) were independently associated with Candida auris infection. Fluconazole resistance was 94.7% in Candida auris isolates, with amphotericin B and echinocandin resistance in 39.5% and 7.9%, respectively. ICU mortality did not differ significantly between Candida auris and non-auris groups (31.6% vs. 34.5%; p = 0.854), and survival analysis showed no statistically significant difference (log-rank p = 0.07).

Conclusion

This study highlights the growing burden of Candida auris in intensive care unit settings, demonstrating a substantial incidence without increased mortality compared to non-auris Candida species. Advancing age and female sex emerged as significant independent risk factors, emphasizing the need for continued surveillance and targeted risk assessment in regions where Candida auris is endemic.

 

 

 

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.

 

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.

 

 

Comparison of all-cause mortality with different blood glucose control strategies in patients with diabetes in the ICU: a network meta-analysis of randomized controlled trials

Annals of Intensive Care volume 15, Article number: 51 (2025) Published: 09 April 2025

Background

The optimal glucose control strategy for intensive care unit (ICU) patients with diabetes remains a topic of debate. This study aimed to compare the effects of strict glucose control, intermediate strict glucose control, liberal glucose control, and very liberal glucose control on reducing all-cause mortality in ICU patients with diabetes through a network meta-analysis.

Methods

We conducted a search in PubMed, Cochrane Library, Embase, and Web of Science for randomized controlled trials comparing different glucose control strategies in ICU patients with diabetes up to October 1, 2024. The primary outcome was all-cause 90-day mortality. The Risk of Bias 2 tool was used to assess bias in the included studies. Data analysis was performed using Stata (version 17).

Results

A total of 12 randomized controlled trials involving 5,297 participants were included in the final analysis. The results showed that there was no statistically significant difference between the four glucose control strategies in reducing all-cause 90-day mortality. The surface under the cumulative ranking (SUCRA), which was used to rank the strategies and display the probability of each strategy being ranked first, showed the following: intermediate strict control (SUCRA 88%), liberal control (SUCRA 55.3%), very liberal control (SUCRA 40.3%), and strict control (SUCRA 16.5%). The cumulative probability of each strategy’s rank in reducing all-cause mortality, from best to worst, showed that the most likely ranking was intermediate strict control, liberal control, very liberal control, and strict control.

Conclusions

In ICU patients with diabetes, no significant statistical difference was observed among the four glucose control strategies in reducing all-cause 90-day mortality. The SUCRA rankings are hypothesis-generating and require further validation. Therefore, the current evidence is insufficient to definitively conclude that any one strategy is superior to the others in reducing mortality.

 

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.

 

 

Impact of sleep disturbances on outcomes in intensive care units

Critical Care volume 28, Article number: 331, Published: 09 October 2024

Background

Sleep deprivation is common in intensive care units (ICUs) and may alter respiratory performance. Few studies have assessed the role of sleep disturbances on outcomes in critically ill patients.

Objectives

We hypothesized that sleep disturbances may be associated with poor outcomes in ICUs.

Methods

Post-hoc analysis pooling three observational studies assessing sleep by complete polysomnography in 131 conscious and non-sedated patients included at different times of their ICU stay. Sleep was assessed early in a group of patients admitted for acute respiratory failure while breathing spontaneously (n = 34), or under mechanical ventilation in patients with weaning difficulties (n = 45), or immediately after extubation (n = 52). Patients admitted for acute respiratory failure who required intubation, those under mechanical ventilation who had prolonged weaning, and those who required reintubation after extubation were considered as having poor clinical outcomes. Durations of deep sleep, rapid eye movement (REM) sleep, and atypical sleep were compared according to the timing of polysomnography and the clinical outcomes.

Results

Whereas deep sleep remained preserved in patients admitted for acute respiratory failure, it was markedly reduced under mechanical ventilation and after extubation (p < 0.01). Atypical sleep was significantly more frequent in patients under mechanical ventilation than in those breathing spontaneously (p < 0.01). REM sleep was uncommon at any time of their ICU stay. Patients with complete disappearance of REM sleep (50% of patients) were more likely to have poor clinical outcomes than those with persistent REM sleep (24% vs. 9%, p = 0.03).

Conclusion

Complete disappearance of REM sleep was significantly associated with poor clinical outcomes in critically ill patients.

 

European Society of Intensive Care Medicine guidelines on end of life and palliative care in the intensive care unit

Intensive Care Med (2024). Published 03 October 2024

Abstract

The European Society of Intensive Care Medicine (ESICM) has developed evidence-based recommendations and expert opinions about end-of-life (EoL) and palliative care for critically ill adults to optimize patient-centered care, improving outcomes of relatives, and supporting intensive care unit (ICU) staff in delivering compassionate and effective EoL and palliative care. An international multi-disciplinary panel of clinical experts, a methodologist, and representatives of patients and families examined key domains, including variability across countries, decision-making, palliative-care integration, communication, family-centered care, and conflict management. Eight evidence-based recommendations (6 of low level of evidence and 2 of high level of evidence) and 19 expert opinions were presented. EoL legislation and the importance of respecting the autonomy and preferences of patients were given close attention. Differences in EoL care depending on country income and healthcare provision were considered. Structured EoL decision-making strategies are recommended to improve outcomes of patients and relatives, as well as staff satisfaction and mental health. Early integration of palliative care and the use of standardized tools for symptom assessment are suggested for patients at high risk of dying. Communication training for ICU staff and printed communication aids for families are advocated to improve outcomes and satisfaction. Methods for enhancing family-centeredness of care include structured family conferences and culturally sensitive interventions. Conflict-management protocols and strategies to prevent burnout among healthcare professionals are also considered. The work done to develop these guidelines highlights many areas requiring further research.

 

Factors associated with cancer treatment resumption after ICU stay in patients with solid tumors

Annals of Intensive Care volume 14, Article number: 135 (2024) Published: 31 August 2024

Background

Post-intensive care syndrome could be responsible for inability to receive proper cancer treatment after ICU stay in patients with solid tumors (ST). Our purpose was to determine the factors associated with cancer treatment resumption and the impact of cancer treatment on the outcome of patients with ST after ICU stay.

Methods

We conducted a retrospective study including all patients with ST admitted to the ICU between 2014 and 2019 in a French University-affiliated Hospital.

Results

A total of 219 patients were included. Median SAPS II at ICU admission was 44.0 [IQR 32.8, 66.3]. Among the 136 patients who survived the ICU stay, 81 (59.6%) received cancer treatment after ICU discharge. There was an important increase in patients with poor performance status (PS) of 3 or 4 after ICU stay (16.2% at admission vs. 44.5% of patients who survived), with significant PS decline following the ICU stay (median difference − 1.5, 95% confidence interval [-1.5-1.0], p < 0.001). The difference between the PS after and before ICU stay (delta PS) was independently associated with inability to receive cancer treatment (Odds ratio OR 0.34, 95%CI 0.18–0.56, p value < 0.001) and with 1-year mortality in patients who survived at ICU discharge (Hazard ratio HR 1.76, 95%CI 1.34–2.31, p value < 0.001). PS before ICU stay (OR 3.73, 95%IC 2.01–7.82, p value < 0.001) and length of stay (OR 1.23, 95%CI 1.06–1.49, p value 0.018) were independently associated with poor PS after ICU stay. Survival rates at ICU discharge, at 1 and 3 years were 62.3% (n = 136), 27.3% (n = 59) and 17.1% (n = 37), respectively. The median survival for patients who resumed cancer treatment after ICU stay was 771 days (95%CI 376–1058), compared to 29 days (95%CI 15–49) for those who did not resume treatment (p < 0.001).

Conclusion

Delta PS, before and after ICU stay, stands out as a critical determinant of cancer treatment resumption and survival after ICU stay. Multidisciplinary intervention to improve the general condition of these patients, in ICU and after ICU stay, may improve access to cancer treatment and long-term survival.

Critical Care Bulletin - July 2024

 

Breathlessness assessment, management and impact in the intensive care unit: a rapid review and narrative synthesis

 

by Ben R. Richardson, Maxens Decavèle, Alexandre Demoule, Fliss E. M. Murtagh and Miriam J. Johnson 

 

Annals of Intensive Care volume 14, Article number: 107, Published: 05 July 2024

 

Background

Adults in the intensive care unit (ICU) commonly experience distressing symptoms and other concerns such as pain, delirium, and breathlessness. Breathlessness management is not supported by any ICU guidelines, unlike other symptoms.

Aim

To review the literature relating to (i) prevalence, intensity, assessment, and management of breathlessness in critically ill adults in the ICU receiving invasive and non-invasive mechanical ventilation (NIV) and high-flow oxygen therapy, (HFOT), (ii) the impact of breathlessness on ICU patients with regard to engagement with rehabilitation.

Methods

A rapid review and narrative synthesis using the Cochrane Methods Group Recommendations was conducted and reported in accordance with PRISMA. All study designs investigating breathlessness in adult ICU patients receiving either invasive mechanical ventilation (IMV), NIV or HFOT were eligible. PubMed, MEDLINE, The Cochrane Library and CINAHL databased were searched from June 2013 to June 2023. Studies were quality appraised.

Results

19 studies representing 2822 ICU patients were included (participants mean age 48 years to 71 years; proportion of males 43–100%). The weighted mean prevalence of breathlessness in ICU patients receiving IMV was 49% (range 34–66%). The proportion of patients receiving NIV self-reporting moderate to severe dyspnoea was 55% prior to initiation. Breathlessness assessment tools included visual analogue scale, (VAS), numerical rating scale, (NRS) and modified BORG scale, (mBORG). In patients receiving NIV the highest reported median (interquartile range [IQR]) VAS, NRS and mBORG scores were 6.2cm (0–10 cm), 5 (2–7) and 6 (2.3–7) respectively (moderate to severe breathlessness). In patients receiving either NIV or HFOT the highest reported median (IQR) VAS, NRS and mBORG scores were 3 cm (0–6 cm), 8 (5–10) and 4 (3–5) respectively.

Conclusion

Breathlessness in adults receiving IMV, NIV or HFOT in the ICU is prevalent and clinically important with median intensity ratings indicating the presence of moderate to severe symptoms.

 

Impact of intensive prone position therapy on outcomes in intubated patients with ARDS related to COVID-19

 

by Christophe Le Terrier, Thaïs Walter, Said Lebbah, David Hajage, Florian Sigaud, Claude Guérin, Luc Desmedt, Steve Primmaz, Vincent Jousselin, Chiara Della Badia, Jean-Damien Ricard, Jérôme Pugin and Nicolas Terzi 

 

Annals of Intensive Care volume 14, Article number: 100, Published: 27 June 2024

 

Background

Previous retrospective research has shown that maintaining prone positioning (PP) for an average of 40 h is associated with an increase of survival rates in intubated patients with COVID-19-related acute respiratory distress syndrome (ARDS). This study aims to determine whether a cumulative PP duration of more than 32 h during the first 2 days of intensive care unit (ICU) admission is associated with increased survival compared to a cumulative PP duration of 32 h or less.

Methods

This study is an ancillary analysis from a previous large international observational study involving intubated patients placed in PP in the first 48 h of ICU admission in 149 ICUs across France, Belgium and Switzerland. Given that PP is recommended for a 16-h daily duration, intensive PP was defined as a cumulated duration of more than 32 h during the first 48 h, whereas standard PP was defined as a duration equal to or less than 32 h. Patients were followed-up for 90 days. The primary outcome was mortality at day 60. An Inverse Probability Censoring Weighting (IPCW) Cox model including a target emulation trial method was used to analyze the data.

Results

Out of 2137 intubated patients, 753 were placed in PP during the first 48 h of ICU admission. The intensive PP group (n = 79) had a median PP duration of 36 h, while standard PP group (n = 674) had a median of 16 h during the first 48 h. Sixty-day mortality rate in the intensive PP group was 39.2% compared to 38.7% in the standard PP group (p = 0.93). Twenty-eight-day and 90-day mortality as well as the ventilator-free days until day 28 were similar in both groups. After IPCW, there was no significant difference in mortality at day 60 between the two-study groups (HR 0.95 [0.52–1.74], p = 0.87 and HR 1.1 [0.77–1.57], p = 0.61 in complete case analysis or in multiple imputation analysis, respectively).

Conclusions

This secondary analysis of a large multicenter European cohort of intubated patients with ARDS due to COVID-19 found that intensive PP during the first 48 h did not provide a survival benefit compared to standard PP.

 

Impact of COVID-19 on posttraumatic stress disorder in ICU survivors: a prospective observational comparative cohort study

 

by Pierre Kalfon, Wissam El-Hage, Marie-Agnès Geantot, Constance Favier, Laetitia Bodet-Contentin, Khaldoun Kuteifan, Pierre-Yves Olivier, Didier Thévenin, Julien Pottecher, Jullien Crozon-Clauzel, Bénédicte Mauchien, Arnaud Galbois, Roland de Varax, Sabine Valera, Philippe Estagnasie, Audrey Berric…

 

Critical Care volume 28, Article number: 77 (2024) Published: 14 March 2024

 

Background

Posttraumatic stress disorder (PTSD) after a stay in the intensive care unit (ICU) can affect one in five ICU survivors. At the beginning of the coronavirus disease 2019 (COVID-19) pandemic, admission to the ICU for COVID-19 was stressful due to the severity of this disease. This study assessed whether admission to the ICU for COVID-19 was associated with a higher prevalence of PTSD compared with other causes of ICU admission after adjustment for pre-ICU psychological factors.

Methods

This prospective observational comparative cohort study included 31 ICUs. Eligible patients were adult ICU survivors hospitalized during the first wave of COVID-19 pandemic in France, regardless of the reason for admission. The prevalence of presumptive diagnosis of PTSD at 6 months was assessed using the PTSD Checklist for DSM-5 (PCL-5). Sociodemographics, clinical data, history of childhood trauma (Childhood Trauma Questionnaire [CTQ]), and exposure to potentially traumatic events (Life Events Checklist for DSM-5 [LEC-5]) were assessed.

Results

Of the 778 ICU survivors included during the first wave of COVID-19 pandemic in France, 417 and 361 were assigned to the COVID-19 and non-COVID-19 cohorts, respectively. Fourteen (4.9%) and 11 (4.9%), respectively, presented with presumptive diagnosis of PTSD at 6 months (p = 0.976). After adjusting for age, sex, severity score at admission, use of invasive mechanical ventilation, ICU duration, CTQ and LEC-5, COVID-19 status was not associated with presumptive diagnosis of PTSD using the PCL-5. Only female sex was associated with presumptive diagnosis of PTSD. However, COVID-19 patients reported significantly more intrusion and avoidance symptoms than non-COVID patients (39% vs. 29%, p = 0.015 and 27% vs. 19%, p = 0.030), respectively. The median PCL-5 score was higher in the COVID-19 than non-COVID-19 cohort (9 [3, 20] vs. 4 [2, 16], p = 0.034).

Conclusion

Admission to the ICU for COVID-19 was not associated with a higher prevalence of PTSD compared with admission for another cause during the first wave of the COVID-19 pandemic in France. However, intrusion and avoidance symptoms were more frequent in COVID-19 patients than in non-COVID-19 patients.

 

Outcomes of patients aged ≥80 years with respiratory failure initially treated with non-invasive ventilation in European intensive care units before and during COVID-19 pandemic

 

by Kamil Polok, Jakub Fronczek, Bertrand Guidet, Antonio Artigas, Dylan W. De Lange, Jesper Fjølner, Susannah Leaver, Michael Beil, Sigal Sviri, Raphael Romano Bruno, Bernhard Wernly, Bernardo Bollen Pinto, Joerg C. Schefold, Dorota Studzińska, Michael Joannidis, Sandra Oeyen… 

 

Annals of Intensive Care volume 13, Article number: 82 (2023)

 

Background

Non-invasive ventilation (NIV) has been commonly used to treat acute respiratory failure due to COVID-19. In this study we aimed to compare outcomes of older critically ill patients treated with NIV before and during the COVID-19 pandemic.

Methods

We analysed a merged cohort of older adults admitted to intensive care units (ICUs) due to respiratory failure. Patients were enrolled into one of two prospective observational studies: before COVID-19 (VIP2—2018 to 2019) and admitted due to COVID-19 (COVIP—March 2020 to January 2023). The outcomes included: 30-day mortality, intubation rate and NIV failure (death or intubation within 30 days).

Results

The final cohort included 1986 patients (1292 from VIP2, 694 from COVIP) with a median age of 83 years. NIV was used as a primary mode of respiratory support in 697 participants (35.1%). ICU admission due to COVID-19 was associated with an increased 30-day mortality (65.5% vs. 36.5%, HR 2.18, 95% CI 1.71 to 2.77), more frequent intubation (36.9% vs. 17.5%, OR 2.63, 95% CI 1.74 to 3.99) and NIV failure (76.2% vs. 45.3%, OR 4.21, 95% CI 2.84 to 6.34) compared to non-COVID causes of respiratory failure. Sensitivity analysis after exclusion of patients in whom life supporting treatment limitation was introduced during primary NIV confirmed higher 30-day mortality in patients with COVID-19 (52.5% vs. 23.4%, HR 2.64, 95% CI 1.83 to 3.80).

Conclusion

The outcomes of patients aged ≥80 years treated with NIV during COVID-19 pandemic were worse compared then those treated with NIV in the pre-pandemic era.

 

Long-term immunosuppressive treatment is not associated with worse outcome in patients hospitalized in the intensive care unit for septic shock: the PACIFIC study

by Julien Vaidie, Edwige Peju, Louise-Marie Jandeaux, Mathieu Lesouhaitier, Jean-Claude Lacherade, Antoine Guillon, Xavier Wittebole, Pierre Asfar, Bruno Evrard, Thomas Daix, Philippe Vignon and Bruno François 

Critical Care volume 27, Article number: 340 (2023) 

 

Background

Except in a few retrospective studies mainly including patients under chemotherapy, information regarding the impact of immunosuppressive therapy on the prognosis of patients admitted to the intensive care unit (ICU) for septic shock is scarce. Accordingly, the PACIFIC study aimed to asses if immunosuppressive therapy is associated with an increased mortality in patients admitted to the ICU for septic shock.

Methods

This was a retrospective epidemiological multicentre study. Eight high enroller centres in septic shock randomised controlled trials (RCTs) participated in the study. Patients in the “exposed” group were selected from the screen failure logs of seven recent RCTs and excluded because of immunosuppressive treatment. The “non-exposed” patients were those included in the placebo arm of the same RCTs. A multivariate logistic regression model was used to estimate the risk of death.

Results

Among the 433 patients enrolled, 103 were included in the “exposed” group and 330 in the “non-exposed” group. Reason for immunosuppressive therapy included organ transplantation (n = 45 [44%]) or systemic disease (n = 58 [56%]). ICU mortality rate was 24% in the “exposed” group and 25% in the “non-exposed” group (p = 0.9). Neither in univariate nor in multivariate analysis immunosuppressive therapy was associated with a higher ICU mortality (OR: 0.95; [95% CI 0.56–1.58]: p =  0.86 and 1.13 [95% CI 0.61–2.05]: p =  0.69, respectively) or 3-month mortality (OR: 1.13; [95% CI 0.69–1.82]: p =  0.62 and OR: 1.36 [95% CI 0.78–2.37]: p =  0.28, respectively).

Conclusions

In this study, long-term immunosuppressive therapy excluding chemotherapy was not associated with significantly higher or lower ICU and 3-month mortality in patients admitted to the ICU for septic shock.