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Current Opinion in Critical Care
Journal Prestige (SJR): 1.382  Citation Impact (citeScore): 3 Number of Followers: 74  Hybrid journal (It can contain Open Access articles)ISSN (Print) 1070-5295 - ISSN (Online) 1531-7072 Published by LWW Wolters Kluwer  [330 journals]
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- Editorial introductions
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PubDate: Thu, 01 May 2025 00:00:00 GMT-
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- The evolving landscape of emergency care
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Authors: Kaplan; Lewis J.
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PubDate: Thu, 01 May 2025 00:00:00 GMT-
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- Cardiopulmonary monitoring in critical care: navigating without
instruments is not an option-
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Authors: Schmidt; Matthieu
Abstract: No abstract available
PubDate: Thu, 01 May 2025 00:00:00 GMT-
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- Advances in resuscitation and deresuscitation
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Authors: Pantet; Olivier; Ageron, François-Xavier; Zingg, Tobias
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Purpose of review This review aims to provide a perspective on fluid resuscitation strategies and emerging trends in deresuscitation, with a particular emphasis on fluid stewardship, monitoring, and personalized fluid management.Recent findings Recent studies underscore a paradigm shift in resuscitation strategies. Notably, aggressive plasma volume expansion has been linked to higher morbidity and mortality, favoring conservative fluid resuscitation. Dynamic parameters, such as pulse pressure variation (PPV) and stroke volume variation (SVV) outperform static markers like central venous pressure (CVP) in predicting preload responsiveness. Advances in hemodynamic monitoring and automated closed-loop fluid administration demonstrate efficacy in optimizing resuscitation. Fluid stewardship, supported by machine learning, is reshaping deresuscitation practices, and promoting negative fluid balance to reduce complications. Moreover, next-generation closed-loop systems and fluid management personalization as part of precision medicine are emerging as future directions.Summary Advances in fluid resuscitation challenge traditional practices, with evidence favoring personalized and goal-directed strategies. Technological innovations in hemodynamic monitoring, automated fluid control, and machine learning are driving precision fluid management. Fluid stewardship and deresuscitation aim to mitigate fluid accumulation syndrome and improve patient outcomes.
PubDate: Mon, 21 Apr 2025 00:00:00 GMT-
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- Monitoring and preserving diaphragmatic function in mechanical ventilation
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Authors: Combet; Margot; Coman, Briar; Telias, Irene
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Purpose of review This review summarizes the evidence on clinical outcomes related to diaphragm dysfunction, providing an overview on available monitoring tools and strategies for its prevention and treatment.Recent findings Long-term adverse functional outcomes in intensive care survivors are well documented, especially in patients with prolonged mechanical ventilation. Because diaphragm weakness is highly prevalent and strongly associated with weaning failure, a link between diaphragm weakness and adverse functional outcomes is probable. Mechanisms of critical illness-associated diaphragm weakness are complex and include ventilator-related myotrauma through various pathways (i.e. over-assistance, under-assistance, eccentric, expiratory). Given this potential clinical impact, research on preventive and therapeutic strategies is growing, including the development of ventilation strategies aiming at protecting both the lung and the diaphragm. Phrenic nerve stimulation and specific rehabilitation strategies also appear promising.Summary Diaphragm dysfunction is associated with adverse clinical outcomes in ventilated patients; therefore, their inspiratory effort and function should be monitored. Whenever possible, and without compromising lung protection, moderate inspiratory effort should be targeted. Phrenic nerve stimulation and specific rehabilitation strategies are promising to prevent and treat diaphragm dysfunction, but further evidence is needed before widespread implementation.
PubDate: Mon, 07 Apr 2025 00:00:00 GMT-
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- Monitoring effort and respiratory drive in patients with acute respiratory
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Authors: Carteaux; Guillaume; Coudroy, Rémi
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Purpose of review Accurate monitoring of respiratory drive and inspiratory effort is crucial for optimizing ventilatory support during acute respiratory failure. This review evaluates current and emerging bedside methods for assessing respiratory drive and effort.Recent findings While electrical activity of the diaphragm and esophageal pressure remain the reference standards for assessing respiratory drive and effort, their clinical utility is largely limited to research. At the bedside, airway occlusion maneuvers are the most useful tools: P0.1 is a reliable marker of drive and detects abnormal inspiratory efforts, while occlusion pressure (Pocc) may outperform P0.1 in identifying excessive effort. The Pressure-Muscle-Index (PMI) can help detecting insufficient inspiratory effort, though its accuracy depends on obtaining a stable plateau pressure. Other techniques, such as central venous pressure swings (ΔCVP), are promising but require further investigation. Emerging machine learning and artificial intelligence based algorithms could play a pivotal role in automated respiratory monitoring in the near future.Summary Although Pes and EAdi remain reference methods, airway occlusion maneuvers are currently the most practical bedside tools for monitoring respiratory drive and effort. Noninvasive alternatives such as ΔCVP deserve further evaluation. Artificial intelligence and machine learning may soon provide automated solutions for bedside monitoring of respiratory drive and effort.
PubDate: Fri, 04 Apr 2025 00:00:00 GMT-
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- Which cardiovascular monitoring on veno-arterial extracorporeal membrane
oxygenation-
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Authors: Dauwe; Dieter F.; Saugel, Bernd; De Backer, Daniel
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Purpose review To discuss the hemodynamic monitoring techniques to quantify cardiac output, to assess the adequacy of perfusion, and to evaluate cardiac as well as pump preload and fluid responsiveness in patients supported by veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Echocardiography is essential in the hemodynamic assessment of VA-ECMO patients. However, intermittent echocardiography should be complemented by continuous, potentially nurse driven, monitoring techniques. We will focus on invasive and noninvasive hemodynamic monitoring methods beyond echocardiography.Recent findings Despite the importance of comprehensive hemodynamic monitoring in the provision of safe, adequate, and well balanced VA-ECMO support, limited data are currently available in this specific patient population. While some measurements (intravascular pressures, oxygen saturation) remain valid and provide important information on the hemodynamic state, measurements of cardiac output are invalid with many of the hemodynamic monitoring methods. Many of the routinely used monitoring methods must be interpreted with caution during VA-ECMO support.Summary A thorough understanding of the various hemodynamic monitoring methods and the physiological interactions between VA-ECMO and patients is essential for selecting the optimal hemodynamic monitoring strategy and correctly interpreting the resulting hemodynamic measurements.
PubDate: Tue, 01 Apr 2025 00:00:00 GMT-
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- The future of artificial intelligence in cardiovascular monitoring
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Authors: Greco; Massimiliano; Lubian, Marta; Cecconi, Maurizio
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Purpose of review Cardiovascular monitoring is essential for managing hemodynamic instability and preventing complications in critically ill patients. Conventional monitoring approaches are limited by predefined thresholds, dependence on clinician expertise, and a lack of adaptability to individual patients. The aim of this review is to explore recent findings about the use of artificial intelligence (AI) in cardiovascular monitoring.Recent findings AI has the potential to transform monitoring in critical care through the automated real-time analysis of extensive, high-resolution datasets, and can facilitate early detection of patient deterioration, minimize false alarms, and support patient clustering for tailored therapeutic strategies. These innovations facilitate a shift toward precision medicine, tailoring treatments based on physiological and temporal data patterns. Moreover, wearable devices can further enhance real-time patient surveillance and risk stratification, extending intensivist monitoring beyond the ICU. Despite advantages, challenges persist, including algorithm generalizability, issues with patient consent and data privacy, and the current lack of external validation. Overcoming these barriers is essential for realizing the full potential of AI in critical care and hemodynamic monitoring.Summary The integration of continuous high-resolution monitoring with AI real-time applications has the potential to transform hemodynamic assessment, enhance clinical decision-making, and improve safety and clinical outcomes.
PubDate: Mon, 24 Mar 2025 00:00:00 GMT-
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- Perioperative risk assessment for emergency general surgery in those with
multimorbidity or frailty-
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Authors: Arda; Yasmin; Kaafarani, Haytham M.A.
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Purpose of review This review explores advances in risk stratification tools and their applicability in identifying and managing high-risk emergency general surgery (EGS) patients.Recent findings Traditional risk assessment tools have several limitations when applied to complex EGS patients as comorbidities are generally treated in a binary, linear and sequential fashion. Additionally, some tools are only usable in the postoperative period, and some require multidisciplinary involvement and are not suitable in an emergency setting. Frailty in particular – for which there are multiple calculators-maladaptively influences outcomes. Artificial intelligence tools, such as the machine-learning-based POTTER calculator, demonstrate superior performance by addressing nonlinear interactions among patient factors, offering a dynamic and more accurate approach to risk prediction.Summary Integrating advanced, data-driven risk assessment tools into clinical practice can help identify and manage high-risk patients as well as forecast outcomes for EGS patients. Such tools are intended to trigger preoperative interventions as well as discussions that ensure goal-concordant care, align expectations with anticipated outcomes and support both facility and patient-relevant outcomes.
PubDate: Wed, 19 Mar 2025 00:00:00 GMT-
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- ICU imperatives in open abdomen management after trauma or emergency
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Authors: Leonard; Jennifer Marie; Cecconi, Maurizio; Kaplan, Lewis J.
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Purpose of review This review is both timely and relevant as the open abdomen approach to manage injury, emergency general surgery (EGS) conditions, as well as secondary intra-abdominal hypertension (IAH) and the abdominal compartment syndrome (ACS) remain prevalent throughout ICUs.Recent findings IAH is not limited to those with injury or EGS conditions, as it is increasingly recognized following cardiac surgery as well as cardiac transplantation. IAH monitoring techniques benefit from technological advances including noninvasive devices. Time to primary fascial closure (PFC) is a key determinant of patient-centered outcomes, with worse outcomes in those with delayed or failed closure attempts. Visceral edema avoidance or mitigation techniques remain controversial. Nutrition support and its impact on the gastrointestinal microbiome appear to influence infection risk and anastomotic integrity. Team-based approaches to successful as well as failed open abdomen management help optimize outcomes.Summary These findings bear broad implications for intensive care medicine clinicians who care for open abdomen patients, as they address resuscitation, intra-abdominal pressure monitoring, and nutrition support all of which influence the likelihood of achieving PFC – a key goal regardless of whether the abdomen was initially left open after injury, EGS, or intestinal ischemia management.
PubDate: Thu, 06 Mar 2025 00:00:00 GMT-
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- When to pursue acute rib fracture fixation
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Authors: Ferre; Alexandra C.; Centeno, Adrian Coleoglou; Vanderploeg, Daniel G.; Pieracci, Frederic M.
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Purpose of review This review will explore acute rib fracture management focusing on indications and timing for acute surgical stabilization of rib fractures (SSRF).Recent findings SSRF is a well tolerated and effective approach for a variety of rib fracture patterns and is most commonly used to correct either clinical flail chest or multiple displaced fractures. Objective tools that assess for deranged pulmonary dynamics may identify patients with other fracture patterns who will also benefit from SSRF. Multimodal analgesia approaches are essential regardless of whether SSRF is pursued; intractable pain may also prompt SSRF. Hemodynamic instability precludes acute SSRF. Otherwise, SSRF should occur within 72 h of injury. Preoperative planning includes thoracic computed tomography scanning, and a preanesthetic evaluation, especially in the geriatric patient based on the presence of comorbidities. Preoperative coordination with other services that also need to address acute injuries helps condense anesthesia exposures. Acute SSRF reduces pain and in particular pulmonary complications in those with acute rib fractures.Summary SSRF is a well tolerated and effectively acutely deployed operative technique to address specific rib fracture injury patterns. It is ideally embraced as a structured program to facilitate collaboration, coordination, and program performance evaluation.
PubDate: Thu, 06 Mar 2025 00:00:00 GMT-
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- Ethical and legal considerations in normothermic regional perfusion for
donation after circulatory death-
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Authors: Walker; Olivia; Testa, Giuliano; Wall, Anji E.
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Purpose of review This study aims to examine the ethical and legal discourse surrounding normothermic regional perfusion (NRP) for donation after circulatory death (DCD).Recent findings NRP is well established within Europe but faces challenges in the US and is not utilized in a variety of other countries. NRP compliance with the dead donor rule (DDR) and Uniform Declaration of Death Act (UDDA) is the most significant recently addressed US ethical and legal issue. Additionally, NRP procedures raise concerns regarding public education, informed consent, public engagement, and trust. Inconsistent NRP regulation – such as in the US– is a cause for concern with the anticipated increase in NRP frequency in support of organ recovery and transplantation. There is no single repository for NRP technical and outcome data to support practice refinement – a key aspect given practice variation between centers and countries.Summary NRP-based organ recovery presents ethical and legal challenges to be addressed by organ donation and transplantation clinicians and organizations in conjunction with public representatives. Additional inquiry into the determination of donor circulatory death, family information needs for authorization, and coordinated regulation of NRP practice is needed to ensure that ethical and legal concerns are appropriately addressed. Public engagement is essential to bolster and preserve trust.
PubDate: Thu, 06 Mar 2025 00:00:00 GMT-
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- Echography monitoring in patients with temporary mechanical circulatory
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Authors: Saura; Ouriel; Hekimian, Guillaume; Schmidt, Matthieu
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Purpose of review To examine the role of echocardiography in managing patients with refractory cardiogenic shock supported by temporary mechanical circulatory support (t-MCS) and provide practical recommendations to improve clinical practice.Recent findings t-MCS devices are increasingly used to stabilize patients with refractory cardiogenic shock. Echocardiography, due to its accessibility and ability to assess both structural and functional aspects of heart failure, is ideally suited for daily bedside evaluation of cardiac function and t-MCS-myocardial interactions.Summary From t-MCS initiation to liberation, echocardiography is essential to guide clinical decision-making. It aids in selecting the most appropriate t-MCS device, ensuring optimal positioning, and fine-tuning flow parameters in real-time based on native cardiac function and patient needs. Additionally, echocardiography is critical for identifying intracardiac complications and directing unloading strategies in venoarterial extracorporeal membrane oxygenation, particularly with very low residual ejection or aortic valve closure. Finally, the weaning process should be informed by comprehensive echocardiographic evaluations, aligned with international guidelines. These steps are outlined in this review, accompanied by clear and practical recommendations to enhance clinical practice.
PubDate: Thu, 06 Mar 2025 00:00:00 GMT-
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- Firearm injury: pushing forward
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Authors: Kern; Joseph A.; Kaufman, Elinore J.
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Purpose of review Recognition of firearm injury as a public health challenge increasingly garners mainstream acceptance, accompanied by increased federal funding for firearm research and federal coordination for firearm injury prevention and response. This review summarizes recent developments relevant to firearm injury epidemiology, prevention, and outcomes.Recent findings Interpersonal firearm violence reached a 30-year peak during the COVID-19 pandemic, but the last 2 years have indicated some improvement. Here, we offer updates regarding firearm injury epidemiology, including disparities according to race, ethnicity, age, sex, and geography. This review summarizes recent literature on risk and protective factors for firearm injury, including aspects related to existing or emerging public policy. New data on the long-term costs and outcomes of firearm injury show pervasive effects, while studies on violence intervention programming, mental health interventions, and coordinated care for survivors of injury offer the potential to improve patient recovery. Lastly, enhanced firearm data infrastructure may yield higher quality research and enable more effective prevention and recovery interventions.Summary Recent findings underscore the multifactorial contributors to the far-reaching public health challenge of firearm injury. Clinicians, researchers, and policy makers must appreciate both the acute and long-term broad consequences of this epidemic to develop, deploy, and evaluate effective interventions to reduce firearm injury harm.
PubDate: Thu, 13 Feb 2025 00:00:00 GMT-
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- Electrical impedance tomography to set positive end-expiratory pressure
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Authors: Francovich; Juliette E.; Katira, Bhushan H.; Jonkman, Annemijn H.
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Purpose of review To summarize the rationale and concepts for positive end-expiratory pressure (PEEP) setting with electrical impedance tomography (EIT) and the effects of EIT-based PEEP setting on cardiopulmonary function.Recent findings EIT allows patient-specific and regional assessment of PEEP effects on recruitability and overdistension, including its impact on ventilation-perfusion (V̇/Q) mismatch. The overdistension and collapse (OD-CL) method is the most used EIT-based approach for PEEP setting. In the RECRUIT study of 108 COVID-19 ARDS patients, the PEEP level corresponding to the OD-CL crossing point showed low overdistension and collapse (below 10% and 5%, respectively) regardless of recruitability. In a porcine model of acute respiratory distress syndrome (ARDS), it was shown that at this crossing point, respiratory mechanics (compliance, ΔP) were consistent, with adequate preload, lower right ventricular afterload, normal cardiac output, and sufficient gas exchange. A recent meta-analysis found that EIT based PEEP setting improved lung mechanics and potentially outcomes in ARDS patients. EIT thus provides critical insights beyond respiratory mechanics and oxygenation for individualized PEEP optimization. EIT-based methods for PEEP setting during assisted ventilation have also been proposed.Summary EIT is a valuable technique to guide individualized PEEP setting utilizing cardiopulmonary information that is not captured by respiratory mechanics and oxygenation response alone.
PubDate: Wed, 12 Feb 2025 00:00:00 GMT-
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- Oxygen delivery and carbon dioxide removal on venovenous extracorporeal
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Authors: Furfaro; David; Supady, Alexander; Abrams, Darryl
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Purpose of review Venovenous extracorporeal membrane oxygenation (VV-ECMO) provides gas exchange for patients with advanced respiratory failure who cannot maintain adequate oxygenation or carbon dioxide (CO2) clearance through conventional mechanical ventilation. This review examines clinical applications of VV-ECMO with a focus on optimizing oxygen delivery and CO2 removal.Recent findings Over the past two decades, VV-ECMO utilization has expanded, now serving as a bridge to recovery in cases of severe hypoxemic and hypercapnic respiratory failure, as procedural support, and as a bridge to lung transplantation. Recent data have corroborated the role of VV-ECMO in managing acute respiratory distress syndrome (ARDS), and guidelines from the American Thoracic Society (ATS) and the European Society of Intensive Care Medicine (ESICM) now recommend it be considered for severe ARDS.Summary This review aims to provide insights into the evolving role of VV-ECMO in the management of critical respiratory failure. Key determinants of oxygenation are discussed, particularly optimizing the ratio of VV-ECMO blood flow to cardiac output (CO). We analyze factors influencing CO2 clearance and review available VV-ECMO configurations and their effects on gas exchange. We discuss practical targets for oxygenation and CO2 removal in VV-ECMO, along with adjunctive techniques for refractory hypoxemia and hypercapnia.
PubDate: Wed, 29 Jan 2025 00:00:00 GMT-
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- Injury induced endotheliopathy: overview, diagnosis, and management
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Authors: Rehani; Chavi; Abdullah, Sarah; Kozar, Rosemary Ann
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Purpose of review This review aims to examine recent advances in the understanding of injury-induced endotheliopathy and therapeutics to mitigate its development in critically injured patients.Recent findings Clinical studies have clearly demonstrated that syndecan-1 ectodomains can be found in circulation after various types of trauma and injury and correlates with worse outcomes. As the mechanisms of endotheliopathy are better understood, pathologic hyperadhesive forms of von Willebrand factor, along with a relative deficiency of its cleaving enzyme, a disintegrin and metalloprotease with thrombospondin type I motifs, member 13 (ADAMTS13), have emerged as additional biomarkers. Therapeutics to date have focused primarily on the protective effects of fresh frozen plasma and its constituents to restore the glycocalyx. Human recombinant ADAMTS13 holds promise, as do synthetic variants of heparan sulfate and activated protein C, although all data to date are preclinical.Summary Injury-induced endotheliopathy represents an important pathologic response to trauma. Key biomarkers, such as syndecan-1, can aid in the diagnosis, but testing is not yet available clinically. As the mechanisms of endotheliopathy are better understood, therapeutics are being identified and show promise. To date, plasma has been the most widely studied; however, like all therapeutics for injury-induced endotheliopathy, it has primarily been studied in the preclinical setting.
PubDate: Fri, 03 Jan 2025 00:00:00 GMT-
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- Monitoring response to prone positioning
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Authors: Guérin; Claude; Grasselli, Giacomo
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Purpose of review The increasing use of prone position, in intubated patients with acute respiratory distress syndrome as well as in patients with acute hypoxemic respiratory failure receiving noninvasive respiratory support, mandates a better definition and monitoring of the response to the manoeuvre. This review will first discuss the definition of the response to prone positioning, which is still largely based on its effect on oxygenation. We will then address monitoring respiratory and hemodynamic responses to prone positioning in intubated patients. Finally, we will also discuss monitoring inspiratory effort in nonintubated patients with acute hypoxemic respiratory failure who breathe spontaneously and receive noninvasive respiratory supportRecent findings The response to prone positioning should be enriched by data pertaining to lung protection beyond oxygenation. These include trans-pulmonary pressure, driving pressure, mechanical power, distribution of aeration and ventilation and assessment of potential for lung recruitment before the pronation.Summary The implications of present findings are to: better select those patients who will benefit from proning in physiological terms, better indicate the timing of onset and end of the sessions, and strengthen the relationship between physiological response and patient outcome.
PubDate: Fri, 03 Jan 2025 00:00:00 GMT-
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