Current opinion in critical care
-
Past observational studies have reported the association between patient-ventilator asynchronies and poor clinical outcomes, namely longer duration of mechanical ventilation and higher mortality. But causality has remained undetermined. During the era of lung and diaphragm protective ventilation, should we revolutionize our clinical practice to detect and treat dyssynchrony? ⋯ Most recent evidence on the topic suggests that synchrony between the patient and the mechanical ventilator is a critical element for protecting lung and diaphragm during the time of invasive mechanical ventilation or may reflect inadequate settings or sedation. Therefore, it is a complex situation, and clinical trials are still needed to test the effectiveness of keeping patient-ventilator interaction synchronous on clinical outcomes.
-
Guidelines recommend systematic performance of a spontaneous breathing trial (SBT) before extubation in ICUs, the objective being to reduce the risk of reintubation. In theory, a more challenging SBT performed with a T-piece may further reduce the risk of reintubation, whereas a less challenging SBT performed with pressure-support ventilation (PSV) may hasten extubation. ⋯ Several recent clinical trials have improved assessment of the most adequate way to perform SBT before extubation.
-
Curr Opin Crit Care · Oct 2024
Monitoring and modulating respiratory drive in mechanically ventilated patients.
Respiratory drive is frequently deranged in the ICU, being associated with adverse clinical outcomes. Monitoring and modulating respiratory drive to prevent potentially injurious consequences merits attention. This review gives a general overview of the available monitoring tools and interventions to modulate drive. ⋯ Monitoring and modulating respiratory drive are feasible based on physiological principles presented in this review. However, evidence arising from clinical trials will help determine precise thresholds and optimal interventions.
-
Curr Opin Crit Care · Oct 2024
ReviewSubgroup analyses and heterogeneity of treatment effects in randomized trials: a primer for the clinician.
To date, most randomized clinical trials in critical care report neutral overall results. However, research as to whether heterogenous responses underlie these results and give opportunity for personalized care is gaining momentum but has yet to inform clinical practice guidance. Thus, we aim to provide an overview of methodological approaches to estimating heterogeneity of treatment effects in randomized trials and conjecture about future paths to application in patient care. ⋯ There is an increasing interest in approaches that can identify heterogeneity in treatment effects from randomized clinical trials, extending beyond traditional subgroup analyses. While prospective validation in further studies is still needed, these approaches are promising tools for design, interpretation, and implementation of clinical trial results.
-
Acute kidney injury (AKI) in critical illness is common, and survivors are faced with a host of adverse outcomes. In this article, we review the current landscape of outcomes and care in survivors of AKI and critical illness. ⋯ Follow-up care of survivors of AKI and critical illness may improve outcomes and there is a need to prioritize transitions of care into the community. Further research is needed to elucidate the best ways to risk-stratify and manage post-AKI survivors to improve outcomes.