搜索结果：Current opinion in critical care

This review synthesizes recent advancements in understanding intracranial compliance (ICC) pathophysiology, explores novel monitoring techniques, and discusses their evolving clinical implications. We highlight how a shift from static intracranial pressure (ICP) thresholds to dynamic ICC assessment is transforming the management of acute brain injury. ICC is the brain's ability to accommodate volume changes without significant ICP elevation, is a critical determinant of outcome in neurocritical care. The paradigm in ICC is evolving from a focus on absolute ICP values to a dynamic, continuous assessment of the brain's compensatory capacity. Emerging concepts extend the classical Monro-Kellie doctrine, incorporating the dynamic roles of cerebrospinal fluid circulation, including the glymphatic system, in maintaining intracranial homeostasis. Integrating new pathophysiological insights with advanced monitoring tools holds immense potential to refine clinical decision-making, enabling more proactive and personalized interventions, ultimately improving outcomes for patients with acute brain injury. To achieve such goal, both invasive and noninvasive advanced monitoring techniques now provide real-time insights into ICC status. ICP waveform analysis offers granular information on compensatory reserve and cerebral autoregulation. Noninvasive methods, such as cranial micro-deformation sensors and transcranial Doppler-derived parameters offer accessible bedside assessment. These tools, alongside others such as optic nerve sheath ultrasound and pupillometry, facilitate earlier detection of decompensation, guide individualized therapy and improve prognostication.

This article provides an overview of intestinal transplantation, focusing on perioperative management and the recognition and treatment of complications in the intensive care unit. The review aims to update intensivists with a comprehensive understanding of the care of intestinal transplant recipients. Despite advances in immunosuppression, donor graft preparation, perioperative care, and the management of complications such as rejection, graft-versus-host disease, and infection, graft and patient survival rates following intestinal transplantation have not improved over the past decade and remain inferior to those of other solid organ transplants. Although surgical techniques have largely remained unchanged, some transplant centers have reported performing intestinal transplantation without a stoma and utilizing preoperative embolization in selected cases.Recent updates in maintenance immunosuppression include the expanded use of less commonly employed agents as part of multimodal regimens such as mammalian target of rapamycin inhibitors and antimetabolites as well as the introduction of therapies not traditionally used for maintenance, including costimulatory blockade, interleukin-2 receptor blockade, and vedolizumab. In recipients of intestinal transplants, prompt identification of infections and complications such as rejection, posttransplant lymphoproliferative disorder, and graft-versus-host disease is essential. Early recognition and intervention are critical to preserving graft function and improving overall survival. Effective management of these perioperative challenges requires a multidisciplinary team approach, with intensivists playing a central role in achieving optimal outcomes.

This review examines recent literature on the pathogenesis, diagnosis, and management of acalculous cholecystitis (AAC), emphasizing evolving imaging, interventional techniques, and risk stratification. Although patients may present a clinical picture of inflammation of the gallbladder without radiographic evidence of calculi within the gallbladder, there is a select group of critically ill patients with unexplained sepsis that require special attention. A major distinction in etiology starts with possible obstructive vs. nonobstructive cholecystitis. Nonobstructive causes of cholecystitis, both from biliary stasis and ischemia, are important for the diagnosis and management of AAC. Recent studies indicate a rising incidence of AAC, likely reflecting an aging population and longer ICU stays in critically ill patients. Diagnostic tools such as ultrasonography and computed tomography remain first-line, whereas hepatobiliary scintigraphy is reserved for indeterminate cases. Emerging trends focus on prevention, improving timely diagnosis, refining risk stratification, and expanding minimally invasive drainage options - including percutaneous and endoscopic approaches - for patients unfit for surgery. Early broad-spectrum antibiotics and preventive strategies are critical to improving outcomes. AAC is a complex and heterogeneous disease with evolving diagnostic and therapeutic paradigms. Preventive strategies are likely to emerge as specific etiology becomes more apparent. Future research should refine predictive algorithms, clarify etiologic distinctions, and optimize interventional management to reduce morbidity in high-risk populations.

Preexisting malnutrition - defined as malnutrition present at the time of ICU admission - represents a critical determinant of outcomes in intensive care. This review summarizes recent evidence regarding its diagnosis, prevalence, clinical significance and nutritional therapy, emphasizing the role of the Global Leadership Initiative on Malnutrition (GLIM) framework. Recent studies applying the GLIM criteria within 24-72 h of ICU admission report malnutrition prevalence ranging from 38 to 68%. Distinguishing preexisting malnutrition from "nutritional risk" is essential, as the former denotes an established nutrient and protein deficit prior to the onset of critical illness. Advances in muscle-mass assessment using various methods have refined phenotypic evaluation. Preexisting malnutrition is consistently associated with prolonged ICU stay, higher infection rates and delayed rehabilitation. While preexisting malnutrition may not markedly influence very short-term outcomes such as 7-day mortality, its influence extends beyond the acute phase, impacting medium-term and long-term trajectories through organ dysfunction, infection risk, persistent muscle wasting and impaired rehabilitation potential. Current evidence does not support early full feeding during the acute phase even in the preexisting malnutrition patients, but highlights the need for sustained, individualized nutritional rehabilitation after ICU discharge and beyond. Preexisting malnutrition is common and clinically impactful among critically ill adults. Incorporating standardized GLIM-based diagnosis into ICU practice enables earlier recognition and tailored nutritional strategies across the continuum of critical care and recovery.

Advances in critical care have improved survival rates after severe brain injuries, yet many patients experience prolonged disorders of consciousness, resulting in significant care burdens and ethical challenges. Therefore, a systematic review of current treatment strategies for these disorders following acute brain injury is essential to provide evidence-based guidance for clinicians, ultimately aiming to enhance patient prognosis and quality of life. Research has rapidly evolved beyond traditional drugs like amantadine and zolpidem, with significant breakthroughs in neuromodulation techniques such as spinal cord stimulation, transcranial direct current stimulation, and brain-computer interfaces. These innovations are reshaping clinical practice by transitioning from theoretical concepts to validated interventions, enabling more precise, individualized treatment protocols. This shift moves clinical management from empirical medication toward targeted neural circuit modulation, while technologies detecting covert consciousness are helping redefine diagnostic standards. The differential effects of these interventions are also advancing fundamental research, deepening understanding of consciousness networks and shifting focus from single targets to whole brain dynamic regulation. These developments collectively highlight the need for integrated multimodal assessment and multilevel interventions, pointing toward a future of personalized, precision medicine for arousal promotion that offers tangible hope for improving patient recovery outcomes and quality of life.

Survival rates following liver transplantation now exceed 90% at one year. However, the patient group undergoing liver transplantation is increasingly complex, requiring continued focus on improving perioperative care to sustain these survival outcomes. This review highlights recent advances in the postoperative care of the liver transplantation patient. Modern care integrates Enhanced Recovery After Surgery (ERAS) principles, which emphasise early mobilisation and device minimisation. Risk stratification has become increasingly sophisticated, with frailty and cardiopulmonary exercise testing providing powerful prognostic information; emerging machine learning approaches may further refine personalised risk prediction.Goal-directed haemodynamic management is advocated, with restrictive fluid strategies and viscoelastic haemostatic assays to minimise transfusion. Advances in graft optimisation have expanded the donor pool: normothermic regional perfusion reduces ischaemic cholangiopathy in donation after cardiac death grafts, while machine perfusion systems show promise in improving early graft function.Advanced organ support (extracorporeal membrane oxygenation) requires careful graft-conscious management. Infection prevention strategies include tailored prophylaxis approaches. Nutrition and structured prehabilitation/rehabilitation programmes support recovery, reduce complications and address persistent functional deficits. Collectively, these developments reflect a shift toward personalised, multidisciplinary postoperative care, aimed at improving both survival and quality of life for liver transplantation recipients.

Mechanical ventilation is life-saving, but is increasingly recognized to be involved in adverse neurological outcomes. Ventilator-associated brain injury (VABI) refers to primary brain dysfunction directly attributable to mechanical ventilation, independent of sedation, hypoxemia, or sepsis. This review summarizes current evidence on the pathophysiology, clinical impact, monitoring strategies, and potential therapeutic interventions for VABI. A growing number of preclinical and clinical studies suggest that mechanical ventilation contributes to hippocampal apoptosis, maladaptive vagal and purinergic signaling, neuroinflammation, blood-brain barrier disruption, altered CO 2 regulation, and nasal airflow abolition. Clinically, VABI may manifest as delirium, disordered sleep, prolonged weaning, and long-term cognitive impairment. Monitoring tools such as electroencephalography, near-infrared spectroscopy, cerebral biomarkers, Doppler ultrasound, and MRI offer complementary but indirect insights. As of today, preventive and therapeutic strategies focus on lung-protective ventilation, limited sedation, early mobilization, and good quality sleep promotion. Some innovative approaches such restoration of nasal airflow, phrenic and vagal stimulation remain experimental. VABI is increasingly recognized as a critical research frontier in critical care medicine. Awareness of its mechanisms and clinical impact should prompt ICU clinicians to integrate brain-oriented practices into routine care. Future trials are needed to evaluate preventive strategies and improve long-term cognitive and functional outcomes for ICU survivors.

Emergency departments (EDs) are playing an increasingly important role in screening for HIV, viral hepatitis, and sexually transmitted infections (STIs), particularly among populations with limited access to routine care. This review examines recent evidence on ED-based screening strategies and evaluates their effectiveness, operational impact, and relevance to acute and critical care settings. Recent pragmatic trials, implementation studies, and large observational analyses have demonstrated that screening outcomes in EDs depend strongly on the screening strategy selected, the infections targeted, and the capacity of downstream care. Targeted opt-in approaches consistently miss infections and rarely increase new diagnoses, even when supported by electronic decision tools. Nontargeted opt-out strategies identify more infections but are associated with higher costs and substantial attrition along the care cascade. In contrast, opt-out syphilis screening has shown marked increases in case detection, particularly among asymptomatic individuals, highlighting important infection-specific differences in screening value. ED-based STI screening is not uniformly beneficial. Its clinical and public health impact depends on selective implementation, infection epidemiology, and robust linkage-to-care systems. Screening strategies aligned with these principles can extend the role of EDs beyond acute care, without compromising their core mission.

Head and neck surgical patients can pose significant management challenges in the ICU postoperatively. In this review, we provide details on the common surgeries that present to the ICU, expected complications and management strategies to improve outcomes. Vital structure involved in breathing, swallowing and neurovascular control are located in the head and neck region posing unique challenges for critical care. A delayed extubation strategy can be performed in select patients and has the advantage of reducing hospital stay, early oral intake, return of speech and decreased respiratory infections compared to a tracheostomy. Recent literature highlights critical interventions to improve outcomes and the importance of a multidisciplinary approach for the management of these patients. These patients require close monitoring for airway compromise, bleeding, neurological deterioration and surgical complications postoperatively. A carefully planned delayed extubation, including a plan for reintubation of a difficult airway may be required in select patients. General management includes tracheostomy care, prevention of deep vein thrombosis, following enhanced recovery after surgery guidelines and maintaining a balance between adequate pain and preservation of airway reflexes. A thorough understanding of the surgery-specific complications and close interaction between the critical care, anesthesiology and surgical teams is paramount.

Mechanical ventilation is essential in acute hypoxemic respiratory failure (AHRF), yet excessive respiratory drive and inspiratory effort may aggravate injury, a phenomenon termed patient self-inflicted lung injury (P-SILI). This review summarizes mechanistic insights, preclinical and clinical evidence, and current strategies to prevent P-SILI while preserving diaphragmatic function. Preclinical experimental studies show that vigorous inspiratory efforts amplify pleural pressure swings, regional overdistension, pendelluft, and inflammation, with damage involving both lung and diaphragm. positive end-expiratory pressure (PEEP) and continuous positive airway pressure (CPAP) can homogenize ventilation, reduce strain-rate, and protect diaphragmatic mechanics, whereas uncontrolled effort worsens outcomes. Clinical investigations confirm that high drive and effort increase total lung stress despite protective tidal volumes and are linked to mortality, ventilator dependence, and complications such as pneumomediastinum. Emerging approaches include titrated pressure support and sedation and ventilatory assistance, neuromuscular blockade, phrenic nerve block, pharmacological drive modulation, prone positioning, and extracorporeal CO 2 removal. Strategies aimed at preserving diaphragm activity, such as electrical phrenic stimulation or inspiratory muscle training, further broaden protective options. P-SILI arises when excessive inspiratory effort translates into injurious lung and diaphragm stress. Preventive strategies should not abolish but shape effort, integrating ventilatory settings, sedation, and drive-modulating interventions across the continuum from the acute phase to weaning and rehabilitation.

In recent years, respiratory muscle training and neurostimulation have emerged as strategies to prevent or reverse respiratory muscle weakness. This review evaluates the latest evidence for respiratory muscle training and neurostimulation as targeted interventions. Inspiratory muscle training (IMT) improves physiological parameters including maximal inspiratory and expiratory pressures, peak expiratory flow, and diaphragm thickness, though clinical trials have not consistently shown benefits in weaning success, ventilator duration, or survival. Evidence for expiratory muscle training (EMT) in ICU patients is scarce, but combined IMT and EMT may improve outcomes. Neurostimulation of the diaphragm and expiratory muscles has advanced from feasibility to early clinical trials. Diaphragm neurostimulation has been demonstrated to improve diaphragm strength and weaning success. Preliminary experimental evidence suggests that diaphragm neurostimulation may also influence lung mechanics, haemodynamics, and brain function. Respiratory muscle training and neurostimulation may attenuate critical illness-associated respiratory muscle weakness. While IMT improves physiological parameters, consistent clinical benefits have not yet been demonstrated. Neurostimulation represents a promising intervention, but further research is required to establish its impact on clinically relevant outcomes and to exclude potential harms when applied in the early phase of critical illness.

As the use of long-acting glucagon-like peptide-1 (GLP-1) drugs in the community grows rapidly, an increasing number of patients in the ICU will be affected by the preexisting GLP-1 therapy. This review highlights recent major advances in the use of GLP-1 drugs and their impact on gastrointestinal function, aiming to assist intensive care clinicians in developing informed management strategies. Although the gastrointestinal inhibitory effects of GLP-1 therapy are well established, this is not clearly associated with inpatient complications. The risk of pulmonary aspiration peri-operatively is low and GLP-1 therapy does not clearly increase this risk peri-operatively. Similarly, there is no clear association with either small intestinal obstruction or acute pancreatitis. The potential impact on enteral nutrition provision is unlikely to be detrimental in the acute phase of critical illness. A systematic approach is necessary to assess gastrointestinal function and monitor for complications. Gastric ultrasound and prokinetic therapy may be useful peri-operatively to detect retained gastric contents and mitigate the risk of pulmonary aspiration. Future research may elaborate the role of GLP-1 therapy in the acute setting for stress hyperglycaemia in the critically ill.

Cardiopulmonary monitoring is fundamental to critical care, yet traditional approaches rely on simplified thresholds that capture only a fraction of the rich information contained within waveforms, imaging, and continuous physiological data. This review examines emerging applications of artificial intelligence (AI) and machine learning (ML) that enhance waveform interpretation, automate point-of-care ultrasound (POCUS), enable predictive monitoring, and extend advanced assessment capabilities into low-resource settings. AI models now identify deterioration earlier than conventional tools, derive complex hemodynamic variables from noninvasive signals, and predict events such as hypotension, cardiac arrest, and sepsis hours in advance. In POCUS, AI enables real-time acquisition guidance and automated cardiac and pulmonary interpretation, allowing novice users to obtain expert-quality studies. Cloud and edge-based architectures further support AI-driven monitoring in austere environments. Despite these advances, most AI systems remain in early development; fewer than 2% have undergone clinical integration, and challenges persist related to generalizability, bias, heterogeneous data quality, and limited prospective evaluation. AI-assisted cardiopulmonary monitoring has the potential to transition critical care from reactive assessment to dynamic, anticipatory management. Realizing this promise will require rigorous validation, workflow integration, and evidence demonstrating true clinical benefit.

Acute respiratory failure is a frequent cause of ICU admission and carries a high mortality rate. Multimodal respiratory monitoring integrating imaging techniques, respiratory mechanics and functional data provides a more comprehensive physiologically grounded assessment of the respiratory status. This review describes recent advances in noninvasive bedside monitoring options that when combined could enable a safer, more personalized management of patients on invasive mechanical ventilation. Quantitative lung ultrasound can be reliably used at the bedside to quantify and monitor the lung density and guide the ventilatory strategy; a recent expert consensus has defined its technical and clinical applications. While providing information on lung morphology, it needs to be combined with other bedside tools such as tidal hysteresis in pressure-volume loops and/or EIT to individualize ventilatory settings. Muscle ultrasound assessment is used to monitor active patients, mainly to quantify patient effort and predict weaning outcomes. Expired CO 2 kinetics evaluates lung efficiency, with important prognostic implications, and new promising developments may allow to continuously estimate static lung volume and cardiac output. Multiple noninvasive bedside tools are available for a multimodal assessment of the respiratory system; while each evaluates the patient from a different perspective, their effectiveness is maximized when they are integrated and combined for daily monitoring and clinical assessment.

Tremendous improvement in the use of artificial intelligence has opened new opportunities to analyze the data obtained from electronic health records and imaging. New technologies have tried to overcome obstacles to implement guidelines and recommendations. This review aims to describe the recent progress in the use of machine learning and new technologies in the field of nutrition of the critically ill. Increase in data availability, ability to extract these data and analyze them using machine learning has allowed data scientists together with ICU specialists to improve nutritional screening and assessment and to predict occurrence of obstacles like enteral feeding intolerance or refeeding hypophosphatemia. In addition, new technologies can ensure nasogastric tube positioning and enteral feeding efficacy. Integrated platforms can integrate nutritional needs with most adequate prescriptions and modulate the nutritional administration according to the patient's tolerance and requirements. Analysis of continuous recording of imaging obtained from ultrasound can also predict gastric intolerance. Using machine learning, numerous algorithms and nomograms have been suggested to predict enteral feeding intolerance but validation of these predictions is still required. New technologies integrating energy requirements and delivery of the optimal enteral feeding are very promising.

Pulmonary embolism (PE) is a common and potentially life-threatening condition for which diagnostic strategies in the emergency department remain challenging. This review provides an updated synthesis of recent advances in PE diagnosis, from pretest probability assessment and D-dimer-guided strategies to imaging selection across settings. In patients with very low clinical probability, pulmonary embolism can be excluded on clinical criteria alone. For low or intermediate probability, using D-dimer thresholds adjusted to clinical probability, including age adjustment, increases specificity and safely reduces imaging. Simplified diagnostic pathways - probability assessment, D-dimer testing, then imaging only if required - improve efficiency when applied consistently. In imaging, low-dose and low-iodine computed tomography pulmonary angiography preserves diagnostic quality, including in pregnancy-adapted workflows. When it is contraindicated, new ventilation-perfusion scintigraphy techniques and magnetic resonance angiography provides contrast-free alternatives in experienced centers. Tailored diagnostic pathways have also been developed for specific populations - such as pregnancy, chronic lung disease, and cancer. Over recent years, the rising number of diagnosed events without a reduction in overall mortality - even as case fatality from pulmonary embolism has decreased - suggests overdiagnosis, driven by detection of smaller or clinically marginal emboli. This supports probability-based testing: anchor decisions in pretest probability, apply thresholds adjusted to the pre-test probability, and reserve imaging for patients likely to benefit. The aim is to balance safety, diagnostic yield, and exposure to radiation and iodinated contrast while preserving overall quality of care.

Helmet noninvasive ventilation (NIV) has gained attention for the management of hypoxemic patients, owing to physiological and potential clinical benefits. We summarize the recent advances on the topic. Compared to facemasks, helmets facilitate application of higher positive end-expiratory pressure (PEEP) for prolonged treatments: this improves oxygenation and may mitigate injurious inflation patterns related to lung heterogeneity. The large, highly compliant interface reduces ventilator triggering performance, causing pressure support to be partially out of phase with patient's inspiratory effort; however, it allows patients to breathe from the internal air reservoir, resulting in formally asynchronous breaths that may help attenuate surges in lung stress and tidal volume without causing flow starvation. Through physiological monitoring, ventilator settings can be individualized to modulate inspiratory effort while limiting increases in dynamic transpulmonary driving pressure and tidal volume. Helmet NIV may offer a valuable strategy for noninvasive management of hypoxemic patients, particularly when applied early, for prolonged periods, and with settings aimed at minimizing injurious inflation in moderate-to-severe (PaO 2 /FiO 2 < 200&#x200a;mmHg) cases. Interface peculiarities affecting patient-ventilator interaction may constitute key differences with facemask NIV for prevention of injurious inflation patterns. Ongoing trials will clarify whether these physiological advantages improve clinical outcomes.

Acute heart failure (AHF) is a frequent, high-risk emergency department presentation in which early diagnostic and therapeutic decisions strongly influence outcomes. This review is timely as new evidence is reshaping the first hours of care, requiring emergency department clinicians to integrate updated diagnostic tools and early guideline-directed treatments. Key diagnostic advances include broader use of cardiopulmonary ultrasound and emerging biomarker-based, machine-learning tools. Noninvasive ventilation remains preferred for severe respiratory distress, while high-flow nasal cannula is widely used despite neutral comparative data. Diuretic strategies are evolving, with natriuresis-guided protocols and combination regimens enhancing decongestion. Vasodilators retain a role in hypertensive AHF. In cardiogenic shock, early inotrope initiation may improve survival, and new agents such as istaroxime show promising hemodynamic effects. Additional emergency department strategies include midazolam for agitation, intravenous iron for iron deficiency, and cautious anti-inflammatory use. Avoiding iatrogenesis - particularly urinary catheterization and prolonged boarding - is crucial, especially in frail patients. Very early initiation of guideline-directed medical therapy, including SGLT2 inhibitors, is increasingly supported. Risk-based disposition using tools such as EHMRG or MEESSI-AHF, combined with structured follow-up, can improve postdischarge outcomes. Integrating these advances may optimize early emergency department management, personalize care, and improve outcomes in AHF.

The vast majority of severe traumatic brain injury (TBI) patients are managed in regions of low resources. Intracranial pressure (ICP) monitoring is, therefore, uncommon. There is insufficient literature to support evidence-based algorithm construction. We here explore current validated models for sTBI management in the absence of ICP monitoring. Prospective trials in LMICs used ad hoc management algorithms for nonmonitored sTBI patients. Subsequent comparison of outcomes employing these algorithms against nonprotocolized care supported benefits from protocolization. Subsequent prospective validation testing of a consensus-based elaboration of ad hoc protocols into a comprehensive management (Consensus-Revised Imaging and Clinical Examination: CREVICE) approach demonstrated the benefits of protocolization on outcome and supported the efficacy of the CREVICE approach. Although at present the only prospectively validated sTBI management algorithm, its applicability is yet limited in generalizability due to resource requirements. Additionally, possible incorporation of noninvasive methods as potential guides for ICP care absent the currently invasive techniques remains untested. Patients with sTBI in the aggregate can be effectively managed when ICP monitoring is not available using currently available validated algorithms. Efficacy in sTBI subgroups (e.g. established intracranial hypertension) is unexplored. Research into noninvasive ICP monitoring and further diminishing resources requirements is necessary.