Key principles for rehabilitation of critically ill patients with obesity

Intensive Care Medicine: Published: 17 July 2026

Purpose

Patients with obesity who are admitted to an ICU bring specific challenges for rehabilitation during and after critical illness. This narrative review explores impact of differences in body compositions and pathophysiology on outcomes to summarise interprofessional, patient-centred rehabilitation strategies across the trajectory of recovery.

Methods

The interprofessional expert panel reviewed major trials and guidelines, integrating their clinical expertise with the current evidence.

Results

Three distinct phenotypes potentially influence outcomes for survivors. Whilst patients with preserved muscle mass may have a survival advantage, the phenotypes characterised by ectopic visceral fat or sarcopenia are frequently complicated by multimorbidity and polypharmacy, likely increasing the risk of adverse effects such as suboptimal sedation, prolonged ventilation and immobilisation, malnutrition, and impaired recovery. Targeted respiratory interventions, including secretion-clearance techniques and appropriate patient positioning to prevent atelectasis, reduce the work of breathing. Optimisation of communication and swallowing function is an essential component for facilitating safe oral intake and promoting active patient participation in rehabilitation. Concurrently, targeted nutrition strategies combined with early, targeted, progressive mobilisation might mitigate ICU acquired weakness and support functional recovery. The availability of appropriate weight‑based equipment is fundamental to ensuring safe mobilisation for both patients and healthcare professionals.

Conclusion

Interprofessional collaboration is central to optimising outcomes and should extend beyond the ICU to structured post-ICU follow-up to address persistent, worsening, or newly emerging health impairments. Early rehabilitation in critically ill patients with obesity should integrate physiological, logistical, and psychosocial considerations to support equitable and functional recovery.

 

 

 

Standard of care for rehabilitation in critical illness

Intensive Care Medicine: Published: 30 April 2026

Background

Rehabilitation is recognised as a cornerstone of intensive care, essential for optimising functional recovery and reducing long-term disability. Contemporary ICU populations, characterised by advanced age, multimorbidity, and prolonged stays, are at heightened risk of muscle wasting, immobility, frailty, cognitive decline, and functional dependence. Mitigation of these sequelae requires careful interprofessional collaboration for person-centred rehabilitation across the care continuum.

Content

This review synthesises evidence from randomised controlled trials, meta-analyses, and clinical practice guidelines on rehabilitation during and after intensive care. Best practice within the ICU begins with early awakening and mobilisation with evidence demonstrating that physical rehabilitation is safe, with low adverse-event rates. Furthermore, multiprofessional strategies that span across ICU, ward, and community are required to address complex problems including physical, cognitive, and psychological sequelae of critical illness.

Future directions

Research priorities include detailed reporting of intervention dose (timing, intensity, duration) for both usual care and rehabilitation provided within clinical trials, and development of intervention implementation strategies that enhance uptake and fidelity in routine practice.

Conclusion

Rehabilitation is integral to contemporary ICU care, spanning the trajectory of recovery into the community. Within the ICU, it requires interprofessional, experienced healthcare personnel to assess clinical status for safe rehabilitation and to identify an individual’s anticipated recovery trajectory. Standardised intervention reporting and implementation-focussed research are essential to advance evidence and improve outcomes for critically ill patients.

 

 

 

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.

 

A prediction model for ‘ICU mortality or prolonged ICU stay’ in critically unwell patients with acute pancreatitis: insights from a 2003–2020 cohort analysis using the ANZICS-CORE database

Critical Care volume 29, Article number: 347, Published: 06 August 2025

Objective

Critically unwell patients with acute pancreatitis (AP) are at increased risk of mortality and prolonged ICU length of stay (LOS). We quantified the frequency, risk factors and complications of prolonged ICU LOS in a large cohort of critically unwell adult patients with AP and developed a model to predict a low-risk trajectory ‘survived ICU with ICU LOS ≤7 days’ versus a high-risk trajectory ‘ICU mortality or ICU LOS > 7 days’.

Methods

A retrospective cohort analysis of adult patients admitted to Australian and New Zealand ICUs with AP between 2003 and 2020 was conducted using the Australian and New Zealand Intensive Care Society Centre for Outcome Reporting and Evaluation database. Data was censored to December 2020 in order to pre-date the COVID-19 pandemic. The incidence, risk factors and outcomes related to prolonged ICU LOS in AP patients was reported. Multivariate logistic regression was used to build a prediction model for a low-risk versus high-risk outcome. Discrimination was performed with 10-fold cross validation and calibration plot analysis was reported.

Main results

13,275 patients met inclusion criteria; 60% were male, with a mean age 59±18, mean APACHE III 56±26. 2860 (21.6%) had an ICU LOS > 7 days, 1022 (7.7%) died in ICU, and 3557 (26.8%) had a high-risk trajectory. Prolonged ICU LOS was associated with increased ICU mortality (OR 1.57 95% CI 1.43–1.73 p < 0.001), hospital mortality (OR 1.69 95% CI 1.56–1.83 p < 0.001), and resource use: mechanical ventilation (OR 5.99 95% CI 5.21–6.90 p < 0.001), inotrope/vasopressor support (OR 3.27 95% CI 2.82–3.79 p < 0.001) and dialysis (OR 4.12 95% CI 3.63–4.68 p < 0.001). Model accuracy was 79.5%, Cohen K = 0.49 and AUROC 0.827. For a high-risk trajectory, sensitivity was 0.54 and specificity 0.916. APACHE III, PaO2:FiO2 ratio and early mechanical ventilation were the most influential covariates. Prolonged ICU LOS was associated with increased rate of hospital discharge to rehabilitation or a nursing home.

Conclusions

More than a quarter of ICU patients with AP have a high-risk trajectory. Prolonged ICU admissions are associated with significantly worse mortality and hospital outcomes, and increase resource use. Our prediction model, if confirmed in future studies, may present an opportunity for prognostic enrichment in patients with more severe disease.

 

Post-extubation dysphagia in the ICU−a narrative review: epidemiology, mechanisms and clinical management (Update 2025)

Critical Care volume 29, Article number: 244 (2025) 

Abstract

Dysphagia (i.e. an impairment in swallowing function that impacts on safety or efficiency) is present in many intensive care unit (ICU) survivors, in particular following extubation (“post-extubation dysphagia”, PED). Despite the fact that pathomechanisms leading to PED are currently incompletely understood, local as well as central neurological and neuromuscular dysfunctions may be key to development of PED. Data from prospective large-scale clinical investigations with systematic screening demonstrate that PED affects about one out of five (about 20%) of mixed medical-surgical unplanned (emergency) ICU admissions. PED is associated with an increased risk for aspiration, aspiration-induced pneumonia, malnutrition, increased ICU resource use, decreased quality of life, prolonged ICU- and hospital length of stay and increased overall morbidity and mortality. Data demonstrate that PED is an independent predictor of 90-day mortality with increased risk of death up to about one year after ICU admission. PED may be a somewhat overlooked medical problem since in many ICUs, PED is currently not routinely screened for in all patients at risk (i.e. all ICU patients) following extubation. In this review, we update the available data on PED with a focus on epidemiology, risk factors, potential aetiology and treatment approaches, as well as clinical management on ICUs.

 

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.

 

Do critical illness survivors with multimorbidity need a different model of care?

 

by Jonathan Stewart, Judy Bradley, Susan Smith, Joanne McPeake, Timothy Walsh, Kimberley Haines, Nina Leggett, Nigel Hart and Danny McAuley 

 

Critical Care volume 27, Article number: 485 (2023) Published: 08 December 2023

 

Abstract

There is currently a lack of evidence on the optimal strategy to support patient recovery after critical illness. Previous research has largely focussed on rehabilitation interventions which aimed to address physical, psychological, and cognitive functional sequelae, the majority of which have failed to demonstrate benefit for the selected outcomes in clinical trials. It is increasingly recognised that a person’s existing health status, and in particular multimorbidity (usually defined as two or more medical conditions) and frailty, are strongly associated with their long-term outcomes after critical illness. Recent evidence indicates the existence of a distinct subgroup of critical illness survivors with multimorbidity and high healthcare utilisation, whose prior health trajectory is a better predictor of long-term outcomes than the severity of their acute illness. This review examines the complex relationships between multimorbidity and patient outcomes after critical illness, which are likely mediated by a range of factors including the number, severity, and modifiability of a person’s medical conditions, as well as related factors including treatment burden, functional status, healthcare delivery, and social support. We explore potential strategies to optimise patient recovery after critical illness in the presence of multimorbidity. A comprehensive and individualized approach is likely necessary including close coordination among healthcare providers, medication reconciliation and management, and addressing the physical, psychological, and social aspects of recovery. Providing patient-centred care that proactively identifies critical illness survivors with multimorbidity and accounts for their unique challenges and needs is likely crucial to facilitate recovery and improve outcomes.

 

Sex and gender differences in intensive care medicine

 

Intensive Care Medicine: Narrative Review: Published: 07 September 2023

 

 

Abstract

Despite significant advancements in critical care medicine, limited attention has been given to sex and gender disparities in management and outcomes of patients admitted to the intensive care unit (ICU). While “sex” pertains to biological and physiological characteristics, such as reproductive organs, chromosomes and sex hormones, “gender” refers more to sociocultural roles and human behavior. Unfortunately, data on gender-related topics in the ICU are lacking. Consequently, data on sex and gender-related differences in admission to the ICU, clinical course, length of stay, mortality, and post-ICU burdens, are often inconsistent. Moreover, when examining specific diagnoses in the ICU, variations can be observed in epidemiology, pathophysiology, presentation, severity, and treatment response due to the distinct impact of sex hormones on the immune and cardiovascular systems. In this narrative review, we highlight the influence of sex and gender on the clinical course, management, and outcomes of the most encountered intensive care conditions, in addition to the potential co-existence of unconscious biases which may also impact critical illness. Diagnoses with a known sex predilection will be discussed within the context of underlying sex differences in physiology, anatomy, and pharmacology with the goal of identifying areas where clinical improvement is needed. To optimize patient care and outcomes, it is crucial to comprehend and address sex and gender differences in the ICU setting and personalize management accordingly to ensure equitable, patient-centered care. Future research should focus on elucidating the underlying mechanisms driving sex and gender disparities, as well as exploring targeted interventions to mitigate these disparities and improve outcomes for all critically ill patients.

Critical Care Bulletin - Feb 2023

 

Toward nutrition improving outcome of critically ill patients: How to interpret recent feeding RCTs?

 

by Jan Gunst, Michael P. Casaer, Jean-Charles Preiser, Jean Reignier and Greet Van den Berghe 

 

Critical Care volume 27, Article number: 43 Published: 27 January 2023

Abstract

Although numerous observational studies associated underfeeding with poor outcome, recent randomized controlled trials (RCTs) have shown that early full nutritional support does not benefit critically ill patients and may induce dose-dependent harm. Some researchers have suggested that the absence of benefit in RCTs may be attributed to overrepresentation of patients deemed at low nutritional risk, or to a too low amino acid versus non-protein energy dose in the nutritional formula. However, these hypotheses have not been confirmed by strong evidence. RCTs have not revealed any subgroup benefiting from early full nutritional support, nor benefit from increased amino acid doses or from indirect calorimetry-based energy dosing targeted at 100% of energy expenditure. Mechanistic studies attributed the absence of benefit of early feeding to anabolic resistance and futile catabolism of extra provided amino acids, and to feeding-induced suppression of recovery-enhancing pathways such as autophagy and ketogenesis, which opened perspectives for fasting-mimicking diets and ketone supplementation. Yet, the presence or absence of an anabolic response to feeding cannot be predicted or monitored and likely differs over time and among patients. In the absence of such monitor, the value of indirect calorimetry seems obscure, especially in the acute phase of illness. Until now, large feeding RCTs have focused on interventions that were initiated in the first week of critical illness. There are no large RCTs that investigated the impact of different feeding strategies initiated after the acute phase and continued after discharge from the intensive care unit in patients recovering from critical illness.

 

Association between early nutrition support and 28-day mortality in critically ill patients: the FRANS prospective nutrition cohort study

by Emmanuel Pardo, Thomas Lescot, Jean-Charles Preiser, Pablo Massanet, Antoine Pons, Samir Jaber, Vincent Fraipont, Eric Levesque, Carole Ichai, Laurent Petit, Fabienne Tamion, Garry Taverny, Priscilla Boizeau, Corinne Alberti, Jean-Michel Constantin and Marie-Pierre Bonnet 

Critical Care volume 27, Article number: 7 Published: 07 January 2023

Background

Current guidelines suggest the introduction of early nutrition support within the first 48 h of admission to the intensive care unit (ICU) for patients who cannot eat. In that context, we aimed to describe nutrition practices in the ICU and study the association between the introduction of early nutrition support (< 48 h) in the ICU and patient mortality at day 28 (D28) using data from a multicentre prospective cohort.

Methods

The ‘French-Speaking ICU Nutritional Survey’ (FRANS) study was conducted in 26 ICUs in France and Belgium over 3 months in 2015. Adult patients with a predicted ICU length of stay > 3 days were consecutively included and followed for 10 days. Their mortality was assessed at D28. We investigated the association between early nutrition (< 48 h) and mortality at D28 using univariate and multivariate propensity-score-weighted logistic regression analyses.

Results

During the study period, 1206 patients were included. Early nutrition support was administered to 718 patients (59.5%), with 504 patients receiving enteral nutrition and 214 parenteral nutrition. Early nutrition was more frequently prescribed in the presence of multiple organ failure and less frequently in overweight and obese patients. Early nutrition was significantly associated with D28 mortality in the univariate analysis (crude odds ratio (OR) 1.69, 95% confidence interval (CI) 1.23–2.34) and propensity-weighted multivariate analysis (adjusted OR (aOR) 1.05, 95% CI 1.00–1.10). In subgroup analyses, this association was stronger in patients ≤ 65 years and with SOFA scores ≤ 8. Compared with no early nutrition, a significant association was found of D28 mortality with early enteral (aOR 1.06, 95% CI 1.01–1.11) but not early parenteral nutrition (aOR 1.04, 95% CI 0.98–1.11).

Conclusions

In this prospective cohort study, early nutrition support in the ICU was significantly associated with increased mortality at D28, particularly in younger patients with less severe disease. Compared to no early nutrition, only early enteral nutrition appeared to be associated with increased mortality. Such findings are in contrast with current guidelines on the provision of early nutrition support in the ICU and may challenge our current practices, particularly concerning patients at low nutrition risk.

 

The rate and assessment of muscle wasting during critical illness: a systematic review and meta-analysis

 

by Brigitta Fazzini, Tobias Märkl, Christos Costas, Manfred Blobner, Stefan J. Schaller, John Prowle, Zudin Puthucheary and Henning Wackerhage 

 

Critical Care volume 27, Article number: 2 Published: 03 January 2023

Background

Patients with critical illness can lose more than 15% of muscle mass in one week, and this can have long-term detrimental effects. However, there is currently no synthesis of the data of intensive care unit (ICU) muscle wasting studies, so the true mean rate of muscle loss across all studies is unknown. The aim of this project was therefore to systematically synthetise data on the rate of muscle loss and to identify the methods used to measure muscle size and to synthetise data on the prevalence of ICU-acquired weakness in critically ill patients.

Methods

We conducted a systematic literature search of MEDLINE, PubMed, AMED, BNI, CINAHL, and EMCARE until January 2022 (International Prospective Register of Systematic Reviews [PROSPERO] registration: CRD420222989540. We included studies with at least 20 adult critically ill patients where the investigators measured a muscle mass-related variable at two time points during the ICU stay. We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and assessed the study quality using the Newcastle–Ottawa Scale.

Results

Fifty-two studies that included 3251 patients fulfilled the selection criteria. These studies investigated the rate of muscle wasting in 1773 (55%) patients and assessed ICU-acquired muscle weakness in 1478 (45%) patients. The methods used to assess muscle mass were ultrasound in 85% (n = 28/33) of the studies and computed tomography in the rest 15% (n = 5/33). During the first week of critical illness, patients lost every day −1.75% (95% CI −2.05, −1.45) of their rectus femoris thickness or −2.10% (95% CI −3.17, −1.02) of rectus femoris cross-sectional area. The overall prevalence of ICU-acquired weakness was 48% (95% CI 39%, 56%).

Conclusion

On average, critically ill patients lose nearly 2% of skeletal muscle per day during the first week of ICU admission.

 

Clustering of critically ill patients using an individualized learning approach enables dose optimization of mobilization in the ICU

 

by Kristina E. Fuest, Bernhard Ulm, Nils Daum, Maximilian Lindholz, Marco Lorenz, Kilian Blobner, Nadine Langer, Carol Hodgson, Margaret Herridge, Manfred Blobner and Stefan J. Schaller 

 

Critical Care volume 27, Article number: 1 Published: 03 January 2023

 

Background

While early mobilization is commonly implemented in intensive care unit treatment guidelines to improve functional outcome, the characterization of the optimal individual dosage (frequency, level or duration) remains unclear. The aim of this study was to demonstrate that artificial intelligence-based clustering of a large ICU cohort can provide individualized mobilization recommendations that have a positive impact on the likelihood of being discharged home.

Methods

This study is an analysis of a prospective observational database of two interdisciplinary intensive care units in Munich, Germany. Dosage of mobilization is determined by sessions per day, mean duration, early mobilization as well as average and maximum level achieved. A k-means cluster analysis was conducted including collected parameters at ICU admission to generate clinically definable clusters.

Results

Between April 2017 and May 2019, 948 patients were included. Four different clusters were identified, comprising “Young Trauma,” “Severely ill & Frail,” “Old non-frail” and “Middle-aged” patients. Early mobilization (< 72 h) was the most important factor to be discharged home in “Young Trauma” patients (ORadj 10.0 [2.8 to 44.0], p < 0.001). In the cluster of “Middle-aged” patients, the likelihood to be discharged home increased with each mobilization level, to a maximum 24-fold increased likelihood for ambulating (ORadj 24.0 [7.4 to 86.1], p < 0.001). The likelihood increased significantly when standing or ambulating was achieved in the older, non-frail cluster (ORadj 4.7 [1.2 to 23.2], p = 0.035 and ORadj 8.1 [1.8 to 45.8], p = 0.010).

Conclusions

An artificial intelligence-based learning approach was able to divide a heterogeneous critical care cohort into four clusters, which differed significantly in their clinical characteristics and in their mobilization parameters. Depending on the cluster, different mobilization strategies supported the likelihood of being discharged home enabling an individualized and resource-optimized mobilization approach.

 

Score-based prediction model for severe vitamin D deficiency in patients with critical illness: development and validation

 

by Yu-Ting Kuo, Li-Kuo Kuo, Chung-Wei Chen, Kuo-Ching Yuan, Chun-Hsien Fu, Ching-Tang Chiu, Yu-Chang Yeh, Jen-Hao Liu and Ming-Chieh Shih 

 

Critical Care volume 26, Article number: 394 (2022)

 

Background

Severe vitamin D deficiency (SVDD) dramatically increases the risks of mortality, infections, and many other diseases. Studies have reported higher prevalence of vitamin D deficiency in patients with critical illness than general population. This multicenter retrospective cohort study develops and validates a score-based model for predicting SVDD in patients with critical illness.

Methods

A total of 662 patients with critical illness were enrolled between October 2017 and July 2020. SVDD was defined as a serum 25(OH)D level of < 12 ng/mL (or 30 nmol/L). The data were divided into a derivation cohort and a validation cohort on the basis of date of enrollment. Multivariable logistic regression (MLR) was performed on the derivation cohort to generate a predictive model for SVDD. Additionally, a score-based calculator (the SVDD score) was designed on the basis of the MLR model. The model’s performance and calibration were tested using the validation cohort.

Results

The prevalence of SVDD was 16.3% and 21.7% in the derivation and validation cohorts, respectively. The MLR model consisted of eight predictors that were then included in the SVDD score. The SVDD score had an area under the receiver operating characteristic curve of 0.848 [95% confidence interval (CI) 0.781–0.914] and an area under the precision recall curve of 0.619 (95% CI 0.577–0.669) in the validation cohort.

Conclusions

This study developed a simple score-based model for predicting SVDD in patients with critical illness.

 

 

Probiotics in Critical Illness: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

 

 by Sharif, Sameer; Greer, Alisha; Skorupski, Clarissa; Hao, Qiukui; Johnstone, Jennie; Dionne, Joanna C.; Lau, Vincent; Manzanares, William; Eltorki, Mohamed; Duan, Erick; Lauzier, Francois; Marshall, John C.; Heels-Ansdell, Diane; Thabane, Lehana; Cook, Deborah J.; Rochwerg, Bram 

 

Critical Care Medicine: May 25, 2022 - Volume - Issue - 10.1097/CCM.0000000000005580

 

Objectives: 

To determine the safety and efficacy of probiotics or synbiotics on morbidity and mortality in critically ill adults and children.

Data Sources: 

We searched MEDLINE, EMBASE, CENTRAL, and unpublished sources from inception to May 4, 2021.

Study Selection: 

We performed a systematic search for randomized controlled trials (RCTs) that compared enteral probiotics or synbiotics to placebo or no treatment in critically ill patients. We screened studies independently and in duplicate.

Data Extraction: 

Independent reviewers extracted data in duplicate. A random-effects model was used to pool data. We assessed the overall certainty of evidence for each outcome using the Grading Recommendations Assessment, Development, and Evaluation approach.

Data Synthesis: 

Sixty-five RCTs enrolled 8,483 patients. Probiotics may reduce ventilator-associated pneumonia (VAP) (relative risk [RR], 0.72; 95% CI, 0.59 to 0.89 and risk difference [RD], 6.9% reduction; 95% CI, 2.7–10.2% fewer; low certainty), healthcare-associated pneumonia (HAP) (RR, 0.70; 95% CI, 0.55–0.89; RD, 5.5% reduction; 95% CI, 8.2–2.0% fewer; low certainty), ICU length of stay (LOS) (mean difference [MD], 1.38 days fewer; 95% CI, 0.57–2.19 d fewer; low certainty), hospital LOS (MD, 2.21 d fewer; 95% CI, 1.18–3.24 d fewer; low certainty), and duration of invasive mechanical ventilation (MD, 2.53 d fewer; 95% CI, 1.31–3.74 d fewer; low certainty). Probiotics probably have no effect on mortality (RR, 0.95; 95% CI, 0.87–1.04 and RD, 1.1% reduction; 95% CI, 2.8% reduction to 0.8% increase; moderate certainty). Post hoc sensitivity analyses without high risk of bias studies negated the effect of probiotics on VAP, HAP, and hospital LOS.

Conclusions: 

Low certainty RCT evidence suggests that probiotics or synbiotics during critical illness may reduce VAP, HAP, ICU and hospital LOS but probably have no effect on mortality.

 

Lung- and Diaphragm-Protective Ventilation by Titrating Inspiratory Support to Diaphragm Effort: A Randomized Clinical Trial

 

by de Vries, Heder J.; Jonkman, Annemijn H.; de Grooth, Harm J.; Duitman, Jan Willem.; Girbes, Armand R. J.; Ottenheijm, Coen A. C.; Schultz, Marcus J.; van de Ven, Peter M.; Zhang, Yingrui; de Man, Angelique M. E.; Tuinman, Pieter R.; Heunks, Leo M. A. 

 

Critical Care Medicine: February 2022 - Volume 50 - Issue 2 - p 192-203

 

OBJECTIVES: Lung- and diaphragm-protective ventilation is a novel concept that aims to limit the detrimental effects of mechanical ventilation on the diaphragm while remaining within limits of lung-protective ventilation. The premise is that low breathing effort under mechanical ventilation causes diaphragm atrophy, whereas excessive breathing effort induces diaphragm and lung injury. In a proof-of-concept study, we aimed to assess whether titration of inspiratory support based on diaphragm effort increases the time that patients have effort in a predefined “diaphragm-protective” range, without compromising lung-protective ventilation.

DESIGN: Randomized clinical trial.

SETTING: Mixed medical-surgical ICU in a tertiary academic hospital in the Netherlands.

PATIENTS: Patients (n = 40) with respiratory failure ventilated in a partially-supported mode. INTERVENTIONS: In the intervention group, inspiratory support was titrated hourly to obtain transdiaphragmatic pressure swings in the predefined “diaphragm-protective” range (3–12 cm H2O). The control group received standard-of-care.

MEASUREMENTS AND MAIN RESULTS: Transdiaphragmatic pressure, transpulmonary pressure, and tidal volume were monitored continuously for 24 hours in both groups. In the intervention group, more breaths were within “diaphragm-protective” range compared with the control group (median 81%; interquartile range [64–86%] vs 35% [16–60%], respectively; p < 0.001). Dynamic transpulmonary pressures (20.5 ± 7.1 vs 18.5 ± 7.0 cm H2O; p = 0.321) and tidal volumes (7.56 ± 1.47 vs 7.54 ± 1.22 mL/kg; p = 0.961) were not different in the intervention and control group, respectively.

CONCLUSIONS: Titration of inspiratory support based on patient breathing effort greatly increased the time that patients had diaphragm effort in the predefined “diaphragm-protective” range without compromising tidal volumes and transpulmonary pressures. This study provides a strong rationale for further studies powered on patient-centered outcomes.

 

 

Hyperglycemia and insulin resistance in COVID-19 versus non-COVID critical illness: Are they really different?

 

by Lies Langouche, Greet Van den Berghe and Jan Gunst 

 

Critical Care volume 25, Article number: 437 (2021) Published: 17 December 2021

 

Hyperglycemia frequently develops in patients with severe COVID-19, regardless of preadmission diabetes status, as in non-COVID critically ill patients. In non-COVID patients, stress hyperglycemia has been attributed to insulin resistance due to elevated counterregulatory hormones, cytokines, and drugs including steroids, although beta-cell dysfunction through prolonged hyperglycemia, poor beta-cell reserve, hypoperfusion and inflammation may co-exist in some patients. As in non-COVID patients, numerous observational studies have associated more severe hyperglycemia and increased glucose variability with poor outcome in COVID-19 patients. However, causality remains unclear, since insulin resistance and resultant hyperglycemia closely relate to illness severity. In this regard, a recent observational study also associated insulin treatment with increased mortality of COVID-19. Evidently, observational studies have an inherent risk of residual confounding, whereby the ideal glucose target can only be derived from adequately powered randomized controlled trials (RCTs)…

 

Delirium in critical illness: clinical manifestations, outcomes, and management

 

Joanna L. Stollings, Katarzyna Kotfis, Gerald Chanques, Brenda T. Pun, Pratik P. Pandharipande & 

E. Wesley Ely 

 

Intensive Care Medicine: 16 August 2021

 

Delirium is the most common manifestation of brain dysfunction in critically ill patients. In the intensive care unit (ICU), duration of delirium is independently predictive of excess death, length of stay, cost of care, and acquired dementia. There are numerous neurotransmitter/functional and/or injury-causing hypotheses rather than a unifying mechanism for delirium. Without using a validated delirium instrument, delirium can be misdiagnosed (under, but also overdiagnosed and trivialized), supporting the recommendation to use a monitoring instrument routinely. The best-validated ICU bedside instruments are CAM-ICU and ICDSC, both of which also detect subsyndromal delirium. Both tools have some inherent limitations in the neurologically injured patients, yet still provide valuable information about delirium once the sequelae of the primary injury settle into a new post-injury baseline. Now it is known that antipsychotics and other psychoactive medications do not reliably improve brain function in critically ill delirious patients. ICU teams should systematically screen for predisposing and precipitating factors. These include exacerbations of cardiac/respiratory failure or sepsis, metabolic disturbances (hypoglycemia, dysnatremia, uremia and ammonemia) receipt of psychoactive medications, and sensory deprivation through prolonged immobilization, uncorrected vision and hearing deficits, poor sleep hygiene, and isolation from loved ones so common during COVID-19 pandemic. The ABCDEF (A2F) bundle is a means to facilitate implementation of the 2018 Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PADIS) Guidelines. In over 25,000 patients across nearly 100 institutions, the A2F bundle has been shown in a dose–response fashion (i.e., greater bundle compliance) to yield improved survival, length of stay, coma and delirium duration, cost, and less ICU bounce-backs and discharge to nursing homes.

Association Between Arterial Hyperoxia and Outcome in Subsets of Critical Illness: A Systematic Review, Meta-Analysis, and Meta-Regression of Cohort Studies

Association Between Arterial Hyperoxia and Outcome in Subsets of Critical Illness: A Systematic Review, Meta-Analysis, and Meta-Regression of Cohort Studies

Critical Care Medicine: July 2015 - Volume 43 - Issue 7 - p 1508–1519 doi:10.1097/CCM.0000000000000998

Helmerhorst, HJF et al

http://journals.lww.com/ccmjournal/Fulltext/2015/07000/Association_Between_Arterial_Hyperoxia_and_Outcome.18.aspx

Objective: Oxygen is vital during critical illness, but hyperoxia may harm patients. Our aim was to systematically evaluate the methodology and findings of cohort studies investigating the effects of hyperoxia in critically ill adults.  A meta-analysis and meta-regression analysis of cohort studies published between 2008 and 2015 was conducted.

Definitive Care for the Critically Ill During a Disaster : Current Capabilities and Limitations

Author(s): Christian , M . D . ; Devereaux , A . V . ; Dichter , J . R . ; Geiling , J . A . ; Rubinson , L .
ISSUE: 2008 ; VOL 133 ; PART 5 ; SUPP
Journal Title: Chest ( Formerly : Diseases of the Chest ) From Free Medical Journals . com (/1995 - /Embargo: 1 year) Customer Notes: 1997 v111/1 - Print Location: Macclesfield

From Proquest NHS (01/1997 - 11/2006)
Page: 8S-17S
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Inhibition of potassium channels in critical illness

Inhibition of potassium channels in critical illness.
Lange M, Morelli A, Westphal M. - click on author link
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