Critical Care Medicine

BackgroundHyperglycemia and hypoglycemia are key risk factors for morbidity and mortality in critically ill septic patients. Despite ongoing research, glucose management guidelines for critically ill patients remain inconsistent, especially for diabetic patients. This study identifies optimal glucose targets to reduce mortality in critically ill patients with sepsis. Research QuestionWhat is the optimal blood glucose range associated with reduced in-hospital mortality for critically ill patients with sepsis, and how does this vary by diabetic status? Study Design and MethodsThis cohort study analyzed 22,374 adult intensive care unit (ICU) patients with sepsis from the MIMIC-IV database. Non-linear logistic regression models assessed the relationship between 72-hour median blood glucose levels and in-hospital mortality, adjusting for age, gender, and Sequential Organ Failure Assessment (SOFA) score. Subgroup analyses explored variations based on diabetic status and other clinical factors. ResultsThe study found a U-shaped relationship between blood glucose levels and mortality, with the lowest risk at 6.3 mmol/L overall and 6.8 mmol/L for diabetic patients. A 5-8 mmol/L glucose range during the first 72 hours was associated with a mortality risk below 10%, representing up to a 5% reduction in mortality compared to the guideline targets of 7.8-10.0 mmol/L. No significant differences were found between patients with or without skin and soft tissue infection. InterpretationThe findings suggest that a tighter glycemic control range of 5-8 mmol/L could improve survival in ICU patients with sepsis, challenging current guidelines. Further randomized controlled trials are necessary to validate and optimize glycemic control strategies for critically ill septic patients. Clinical Trial RegistrationNot applicable. Take-Home PointsO_ST_ABSStudy QuestionC_ST_ABSWhat is the optimal blood glucose level for reducing mortality in critically ill patients with sepsis? ResultsA U-shaped relationship was found, with the lowest mortality risk at 6.3 mmol/L overall and 6.8 mmol/L for people with diabetes. Patients with a 5-8 mmol/L glycemic range had an approximate 50% reduced mortality risk compared to those who maintained glycemic ranges within existing guideline recommendations. InterpretationUnlike the guideline-recommended glucose targets of 7.8 - 10mmol/L, a tighter glycemic target (5-8 mmol/L) may improve mortality for critically ill patients with sepsis.

ObjectiveTo develop a comprehensive checklist, define critical actions, and establish a minimal passing standard for adult and pediatric critical care clinicians as well as other providers to facilitate formative and summative assessment of brain death/death by neurologic criteria (BD/DNC) determination Design: A pre-specified three round modified Delphi consensus process to define checklist items followed by a modified Angoff standard setting process to determine critical actions and item average ratings. SettingElectronic surveys. SubjectsSelected authors of the 2023 Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Practice Guideline, World Brain Death Project, and experts recommended by these authors (n=16) participated in the Delphi panel. Neurocritical care United Council for Neurologic Subspecialties and Accreditation Council for Graduate Medical Education examination committee members (n= 13) participated in Angoff standard setting. InterventionsNone. Measurements and Main ResultsA total of 98 unique checklist items related to assessment of prerequisites (23 items), performance of the clinical examination (28 items), apnea testing (36 items), and ancillary testing (11 items) were retained by the Delphi panel. Seven items were designated as critical actions based upon Angoff panelist consensus. The remaining 91 items were assigned item average ratings. The minimum passing score for an assessment including all items was set at 89%. ConclusionsThese guideline-concordant consensus checklist items, including critical actions and non-critical actions with their assigned item average ratings, may be applied selectively to simulated cases of BD/DNC determination for adults and children to determine a minimum passing score and readiness for independent practice, mitigating risk of inaccurate BD/DNC determination among critical care clinicians. Our process for systematically defining critical actions on a behavior checklist may be replicated for simulation-based summative assessment of learners in other critical care scenarios. KEY POINTSO_ST_ABSQuestionC_ST_ABSWhat behaviors should be included in a checklist for assessment of brain death/death by neurologic criteria (BD/DNC) determination and what level of performance is consistent with readiness for independent practice? FindingsA modified Delphi panel identified 98 checklist items which may be applied selectively to simulated cases of BD/DNC. An Angoff panel identified 7 critical actions and set average ratings for all other items. MeaningThese guideline-concordant consensus checklist items and their average ratings may be applied to assessments of simulated or real cases of BD/DNC, including those intended for summative assessment, to determine learner readiness for independent determination.

Rationale. Racial disparities in outcomes among patients with acute respiratory failure are well-described, but the contributions of clinicians to these disparities have not been evaluated. Objectives. Among mechanically ventilated patients, we evaluated racial disparities in severity of illness trajectories and adapted value-added modeling to quantify nurse and physician relationships with these disparities. Methods. In a retrospective cohort of mechanically ventilated patients across five hospitals between 2018 and 2022, we used generalized estimating equations to model the change in Laboratory-based Acute Physiology Score version 2 (LAPS) from the start to end of intensive care unit admission ({Delta}LAPS). Consistent with value-added modeling, we randomly allocated the cohort into development and testing partitions, and fit separate multiple linear regression models of {Delta}LAPS using concurrent nurse and physician assignments (determined at 4-hour intervals), patient race, and clinician-race interaction terms as fixed effects. Clinician-specific and clinician-race interaction coefficients were extracted to determine race-specific value-add for each clinician. We defined the race-contextual value-add difference (RCVAD) as a clinician-level measurement of the difference in that clinician's value-add between Black and White patients in their care; a positive RCVAD indicates a more favorable severity of illness trajectory for Black relative to White patients and vice versa. Measurement and Main Results. Among 6,555 distinct patients, 7,247 clinical encounters, 405 nurses, and 70 physicians, Black patients accounted for 2,926 (40%) encounters. Overall, Black patients had significantly less improvement in {Delta}LAPS than White patients (difference in LAPS decline = 2.26 [0.23, 4.29], p=0.029). In the development partition, median nurse RCVAD was -0.10 (interquartile range [IQR]: -1.17, 1.14) with 191 (47%) nurses having a positive RCVAD; median physician RCVAD was -0.18 (IQR: -1.34, 0.56) with 29 (41%) having a positive RCVAD. Conclusions. Black mechanically ventilated patients experience less improvement in severity of illness during intensive care unit admission than White patients. While the majority of physicians and nurses were associated with disparities-exacerbating illness trajectories, many other clinicians were associated with disparities-mitigating trajectories. Future work to understand practices associated with disparities-exacerbating and disparities-mitigating care profiles could inform interventions to reduce disparities overall.

BackgroundSepsis-related organ dysfunction results from complex interactions between systemic hemodynamics, microcirculatory alterations, and cellular metabolic failure. Conventional resuscitation strategies guided by global parameters may miss persistent tissue hypoperfusion, a phenomenon termed "hemodynamic incoherence." The PRISM trial was designed to determine whether individualized management guided by advanced multimodal circulatory and perfusion monitoring improves outcomes in septic shock. MethodsThe PRISM trial is a multicenter, randomized, controlled, open-label study with blinded outcome assessment. Adults with septic shock (Sepsis-3 criteria) are randomized (1:1) to structured multimodal monitoring versus standard care. The intervention integrates advanced systemic hemodynamic indices --including mean circulatory filling pressure analogue and other determinants of venous return, heart efficiency, cardiac power output, power efficiency, and volume efficiency-- with a comprehensive perfusion panel (capillary refill time, mottling score, temperature gradients, lactate kinetics, central venous oxygen saturation, venous-arterial carbon dioxide difference, near-infrared spectroscopy-derived skeletal muscle tissue oxygen saturation, and arterial-interstitial glucose gradients). A predefined treatment algorithm links abnormal thresholds to therapeutic interventions. The primary endpoint is change in SOFA and SAPS II scores from baseline to 72 hours. Secondary endpoints include 28-day mortality, ICU and hospital length of stay, ventilator- and vasopressor-free days, lactate clearance, and safety outcomes. DiscussionBy combining advanced hemodynamic physiology with structured multimodal perfusion monitoring, the PRISM trial tests whether individualized, pathophysiology-guided resuscitation can overcome hemodynamic incoherence and improve patient-centered outcomes in septic shock.

PurposeThe goal of this study was to compare noninvasive respiratory support to invasive mechanical ventilation as the initial respiratory support in COVID-19 patients with acute hypoxemic respiratory failure. MethodsAll patients admitted to a large healthcare network with acute hypoxemic respiratory failure associated with COVID-19 and requiring respiratory support were eligible for inclusion. We compared patients treated initially with noninvasive respiratory support (noninvasive positive pressure ventilation by facemask or high flow nasal oxygen) with patients treated initially with invasive mechanical ventilation. The primary outcome was time-to-in-hospital death analyzed using an inverse probability of treatment weighted Cox model adjusted for potential confounders. Secondary outcomes included unweighted and weighted assessments of mortality, lengths-of-stay (intensive care unit and hospital) and time-to-intubation. ResultsOver the study period, 2354 patients met inclusion criteria. Nearly half (47%) received invasive mechanical ventilation first and 53% received initial noninvasive respiratory support. There was an overall 38% in-hospital mortality (37% for invasive mechanical ventilation and 39% for noninvasive respiratory support). Initial noninvasive respiratory support was associated with an increased hazard of death compared to initial invasive mechanical ventilation (HR: 1.61, p < 0.0001, 95% CI: 1.33 - 1.94). However, patients on initial noninvasive respiratory support also experienced an increased hazard of leaving the hospital sooner, but the hazard ratio waned with time (HR: 0.97, p < 0.0001, 95% CI: 0.96 - 0.98). ConclusionThese data show that the COVID-19 patients with acute hypoxemic respiratory failure initially treated with noninvasive respiratory support had an increased hazard of in-hospital death.

RATIONALEThe optimal treatment for early hypoxemic respiratory failure is unclear, and both high-flow nasal cannula and non-invasive ventilation are used. Determining clinically relevant outcomes for evaluating non-invasive respiratory support modalities remains a challenge. OBJECTIVESTo compare the effectiveness of initial treatment with high-flow nasal cannula versus non-invasive ventilation for acute hypoxemic respiratory failure. METHODSWe conducted a retrospective cohort study of patients with acute hypoxemic respiratory failure treated with high-flow nasal cannula or non-invasive ventilation within 24 hours of Emergency Department arrival (1/2018-12/2022). We matched patients 1:1 using a propensity score for odds of receiving non-invasive ventilation. The primary outcome was major adverse pulmonary events (28-day mortality, ventilator-free days, non-invasive respiratory support hours) calculated using a Win Ratio. MEASUREMENTS AND MAIN RESULTS1,265 patients met inclusion criteria. 795 (62.8%) received high-flow oxygen and 470 (37.2%) received non-invasive ventilation. We propensity score matched 736/1,265 (58.2%) patients. There was no difference between non-invasive ventilation vs high-flow nasal cannula in 28-day mortality (17.7% vs 23.1%, p=0.08) or ventilator-free days (median [Interquartile Range]: 28 [25, 28] vs 28 [13, 28], p=0.50), but patients on non-invasive ventilation required treatment for fewer hours (median 7 vs 13, p< 0.001). Win Ratio for composite major adverse pulmonary events favored non-invasive ventilation (1.26, 95%CI 1.06-1.49, p< 0.001). CONCLUSIONSIn this observational study of patients with acute hypoxemic respiratory failure, initial treatment with non-invasive ventilation was superior to high-flow nasal cannula for major pulmonary adverse events. Evaluation of composite outcomes is important in the assessment of respiratory support modalities.

ImportanceThe COVID-19 pandemic has increased the need for high-quality evidence in critical care, while also increasing the barriers to conducting the research needed to produce such evidence. ObjectiveTo determine the effect of the first wave of the COVID-19 pandemic on critical care clinical research. DesignMonthly electronic survey (March 2020 - February 2021). SettingAdult or pediatric intensive care units (ICUs) from any country participating in at least one research study before the COVID-19 pandemic. ParticipantsWe recruited one researcher or research coordinator per center, identified via established research networks. Intervention(s)None Main Outcome(s) and Measure(s)Primary: Suspending recruitment in clinical research; Secondary: impact of specific factors on research conduct (5-point scales from no effect to very large effect). We assessed the association between research continuity and month, presence of hospitalized patients with COVID-19, and population (pediatric vs. adult ICU) using mixed-effects logistic regression. Results127 centers (57% pediatric) from 23 countries participated. 95 (75%) of centers suspended recruitment in at least some studies and 37 (29%) suspended recruitment in all studies on at least one month. The proportion of centers reporting recruitment in all studies increased over time (OR per month 1.3, 95% CI 1.2 to 1.4, p < 0.001), controlling for hospitalized patients with COVID-19 and type of ICU (pediatric vs. other). The five factors most frequently identified as having a large or very large effect on clinical research were: local prioritization of COVID-19 specific research (68, 54%), infection control policies limiting access to patients with COVID-19 (61, 49%), infection control policies limiting access to the ICU (52, 41.6%), increased workload of clinical staff (38, 30%), and safety concerns of research staff (36, 29%). Conclusions and RelevanceDecisions to pause or pursue clinical research varied across centers. Research activity increased over time, despite the presence of hospitalized patients with COVID-19. Guiding principles with local adaptation to safely sustain research during this and future pandemics are urgently needed. Key PointsO_ST_ABSQuestionC_ST_ABSWhat was the effect of the COVID-19 pandemic on research in 127 adult and pediatric intensive care units (ICUs) between March 2020 and February 2021? Findings95 (75%) centers suspended recruitment into at least some studies. Active recruitment into studies increased over time (OR per month 1.3, 95% CI 1.2 to 1.4, p < 0.001), controlling for ICU type and the presence of patients with COVID-19. MeaningResearch activity varied across centers and increased over time, despite the presence of hospitalized patients with COVID-19. Guiding principles to safely sustain research during this and future pandemics are urgently needed.

ObjectiveTo develop and validate a predictive model incorporating behavioral telemetry signals--documentation pattern anomalies derived from routine EHR charting--alongside clinical variables for ICU mortality prediction in patients with low acute physiologic derangement. Materials and MethodsRetrospective cohort study of 46,002 adult ICU stays from MIMIC-IV v3.1 (2008-2022) with SOFA scores 0-2, excluding neurological units. We extracted 66 variables spanning demographics, acuity, behavioral telemetry, clinical enrichment, and temporal factors. Progressive logistic regression models (M1-M7) were compared using cross-validation, DeLong tests, net reclassification improvement, and calibration analysis. ResultsOverall mortality was 9.34% (4,295 deaths). The clinical model (M5) achieved cross-validated AUROC 0.691 versus 0.639 for demographics alone (M2; {Delta}AUROC = 0.052, DeLong p = 4.41x10-47). NRI was 24.3%. Discordant care patients received 30.5% more chart events than concordant patients, with the sole deficit in neurological assessments (-15.4%), refuting the neglect hypothesis. Kaplan-Meier analysis confirmed survival separation (log-rank {chi}2 = 138.6, p = 5.32x10-32). In the most conservative subgroup (SOFA 0, no sedation, no ventilation, N = 11,158), orientation omission remained associated with mortality (adjusted OR 1.52, p = 0.027). DiscussionDeep sedation and mechanical ventilation function as mediators on the causal pathway rather than traditional confounders; the discordant care signal retains significance after full sedation adjustment. ConclusionDocumentation pattern analysis adds measurable predictive value for ICU mortality risk stratification and represents a novel signal for real-time EHR-based clinical decision support.

BackgroundEarly lactate is widely used to risk-stratify septic shock, yet clinically actionable cut-offs for 28-day mortality remain uncertain. MethodsIn a single-centre study conducted across two intensive care units, we analysed 84 adults with septic shock identified within 24 hours of intensive care unit admission. The primary endpoint was 28-day mortality. Four lactate metrics obtained during the first 24 hours were evaluated: first (admission) lactate, last lactate, peak lactate, and lactate clearance from first to last. Associations were tested using logistic regression with and without adjustment for the Simplified Acute Physiology Score 3; discrimination was assessed by area under the receiver-operating characteristic curve (AUROC), and optimal cut-offs were defined by the Youden index. ResultsThirty-nine of 84 patients (46.4%) died by day 28. Higher absolute lactate values were independently associated with death (adjusted odds ratio (OR) per 1 mmol/L increase: First 1.47, p<0.001; Last 1.41, p=0.002; Peak 1.39, p<0.001), whereas Lactate clearance was not (OR 0.65, p=0.202). Discrimination was moderate to good for peak (AUROC 0.817), first (0.791), and last (0.757) lactate, and poor for clearance (0.577). Youden-derived thresholds provided pragmatic trade-offs: First 3.55 mmol/L (sensitivity 0.821, specificity 0.689), Last 3.15 mmol/L (0.567, 0.864), and Peak 3.55 mmol/L (0.973, 0.556). Kaplan-Meier curves using these cut-offs showed early and sustained separation. ConclusionsIn adults with septic shock, simple early lactate thresholds around 3.3- 3.6 mmol/L (first/peak) and approximately 3.15 mmol/L (last) identify 28-day mortality risk and outperform lactate clearance.

PurposeInvasive mechanical ventilation is utilized in over 50% of Australian Intensive Care Unit patients, with rates increasing world-wide. Prolonged mechanical ventilation is associated with increased length of hospital stay and in-hospital mortality compared with patients ventilated under the time threshold. Previous studies have highlighted mortality rates, but much remains unknown regarding the long-term physiological, functional, and psychiatric effects of prolonged mechanical ventilation. With a greater understanding of these outcomes, models of care can be formulated to reduce long-term morbidity. MethodsMedline, CINAHL and the Cochrane Library were searched between 1998 and March 2019, for PMV, patients in ICU and long-term outcomes. Included studies had patients, that received greater than or equal to 14 days of IMV. Primary outcome was mortality rates with secondary outcomes clustered into physiological, functional, and psychiatric outcomes. Results1057 studies were identified, with 24 included. 73% of PMV patients were discharged from ICU, with mortality rates of 57% and 69% at 12 and 48 months. 30.2% were discharged home, 25% developed new onset ventilator acquired pneumonia and up to 39% experienced psychiatric complications. ConclusionDespite a high proportion of patients surviving to hospital discharge, subsequent outcomes are extremely poor for patients that require PMV.

IntroductionIntraoperative glycemic dysregulation, including unrecognized hypoglycemia and stress-induced hyperglycemia, is common during elective surgery. Conventional point-of-care (POC) monitoring provides only intermittent measurements, limiting the anesthesiologists ability to detect rapid glucose fluctuations. Continuous glucose monitoring (CGM) enables real-time, trend-based assessment, potentially shifting intraoperative glycemic management from reactive to proactive. ObjectiveTo meta-analyze the analytical accuracy, intraoperative glycemic efficacy, and feasibility of subcutaneous CGM in adults undergoing elective surgery, informing anesthesiology practice. MethodsThis systematic review and meta-analysis followed the PRISMA 2020 statement. Searches were conducted in PubMed, Embase, and Cochrane Central Register of Controlled Trials from January 2010 to May 2025. Eligible studies included randomized controlled trials and prospective cohorts of adults undergoing elective surgery under general or neuraxial anesthesia using subcutaneous CGM. Primary outcomes were pooled mean absolute relative difference (MARD) and time in range (TIR, 70-180 mg/dL). Random-effects models were applied. ResultsTen studies (3 RCTs, 7 cohorts; N=557) were included. Pooled MARD was 14.1% (95% CI 11.3-16.9%; I{superscript 2}=78%), lower in non-cardiac surgery (12.7%) than cardiac procedures with hypothermia (19.2%; p=0.03). CGM improved TIR by +14.9 percentage points (95% CI 7.2-22.6; p<0.001). Clinically significant hypoglycemia was detected in 43% of patients, all missed by POC. Sensor availability exceeded 96%, with no serious device-related events. ConclusionSubcutaneous CGM provides acceptable intraoperative accuracy and improves glycemic control, supporting its integration into anesthetic management.

ObjectivesTo summarize the effects of intravenous corticosteroid treatment for sepsis defined by the Sepsis-3 criteria in adult patients. DesignSystematic review and meta-analysis. MethodsWe searched RCTs from PubMed, Embase, ClinicalTrials.gov, Cochrane Central Register of Controlled Trials, Web of Science, and International Clinical Trials Registry Platform from inception to July 12th, 2019 and updated on June 28th, 2020. Conference proceedings from relevant societies and the reference lists of previous reviews were manually screened. Abstract or full-text articles were screened by two independent investigators. We included RCTs where (1) the participants had infections and the baseline Sequential Organ Failure Assessment (SOFA) score [&ge;] 2 (the Sepsis-3 definitions) (2) the intervention involved any intravenous corticosteroids; (3) the control group received placebo or standard of care (4) the outcomes of interest included mortality or clinical recovery. We chose the 28-day mortality as the pre-specified primary outcome and risk ratio (RR) as the effect measure. We followed PRISMA guidelines and chose random-effects models for the pooled analyses. ResultsThis study included 24 RCTs and 19 of them (7,115 participants) reported the 28-day mortality. Pooled analyses showed that intravenous corticosteroid treatment compared to placebo or standard of care was not associated with a lower risk of 28-day mortality (RR, 0.88; 95%CI, 0.73 to 1.05), but with a higher risk of hyperglycemia (RR, 1.16; 95%CI, 1.06 to 1.27). Sensitivity analysis of high-quality studies revealed a similar result for the 28-day mortality (RR, 0.95; 95%CI, 0.86 to 1.05). ConclusionsOur findings suggested that intravenous corticosteroids compared to placebo or standard of care may not reduce the 28-day mortality in adult patients with sepsis defined by the Sepsis-3 criteria. Further studies are warranted to clarify the roles of disease severity and treatment timing in the effects of corticosteroid treatment in this population. PROSPERO registration numberCRD42019143083 Strengths and limitations of this studyO_LIThis is the first systematic review and meta-analysis that summarized the effects of intravenous corticosteroid treatments in patients with sepsis defined by the Sepsis-3 criteria. C_LIO_LIWe provide the quality of evidence to support the development of treatment guidelines specific to the Sepsis-3 cohort. C_LIO_LIWe only include randomized controlled trials in this systematic review and meta-analysis, which exclude less controlled evidences from clinical settings closer to our daily practice. C_LIO_LIThe Sepsis-3 definitions will be retrospectively applied to the included studies, so clinical trials without enough reported baseline data available may be excluded. C_LI

The Sequential Organ Failure Assessment (SOFA)-2 score was recently validated for ICU mortality prediction across more than 3 million admissions but was not evaluated across demographic subgroups. We assessed the discrimination and calibration of the SOFA-2 score for ICU mortality across subgroups defined by age, sex, race and ethnicity, primary language, and insurance status. We conducted a retrospective cohort study of adult patients (aged 18 years or older) admitted to ICUs at Beth Israel Deaconess Medical Center between 2008 and 2022 (MIMIC-IV, version 3.1), selecting the first ICU admission per patient. First-day SOFA-2 scores (range, 0-24) were calculated using worst recorded values across 6 organ systems. Discrimination was assessed using AUROC, calibration using intercepts and slopes, and subgroup differences using bootstrap resampling. Among 64,015 ICU admissions (median age, 66 years [IQR, 54-78]; 56.1% male; 66.1% White), overall ICU mortality was 7.2% (n=4,596). Overall AUROC was acceptable at 0.77 (95% CI, 0.76-0.77). Notably, discrimination declined significantly with age: AUROC was 0.85 (95% CI, 0.83-0.87) for ages 18-44 and 0.72 (95% CI, 0.70-0.73) for ages 75 and older (difference in AUROC, -0.14; 95% CI, -0.16 to -0.11), with systematic underprediction of mortality in older patients (calibration intercept, 0.39). Discrimination was also significantly lower among non-English speakers (difference in AUROC, -0.04; 95% CI, -0.07 to -0.01) but did not differ significantly across documented racial and ethnic groups. Patients with unknown race/ethnicity (14.3% of the cohort) had nearly double the overall mortality rate and poor calibration. SOFA-2 demonstrated good overall performance for ICU mortality prediction but with clinically meaningful variation across demographic subgroups, particularly a substantial decline in discrimination with advancing age. These findings underscore the need for routine equity evaluation of clinical prediction tools before widespread implementation.

ImportanceDifferential use of therapies for respiratory failure according to patient race/ethnicity may represent health inequity and could impact patient survival. ObjectiveMeasure the association between patient race/ethnicity and the use of invasive ventilation, and the impact of any association on survival. DesignRetrospective cohort analysis using a Bayesian multistate model that adjusted for baseline covariates and time-varying severity. SettingMulticenter study using the Medical Information Mart for Intensive Care IV (MIMIC-IV) and Phillips eICU (eICU) databases from the USA. ParticipantsNon-intubated adults receiving oxygen within the first 24 hours of ICU admission. ExposurePatient race/ethnicity (Asian, Black, Hispanic, white). Main outcomes and measuresPrimary output was the cause-specific hazard ratio (HR) of invasive ventilation for patient race/ethnicity. Secondary output was change in 28-day survival mediated by differences in invasive ventilation rate. We reported posterior means and 95% credible intervals (CrI). ResultsWe studied 38,263 patients, 52% (20,033) from MIMIC-IV and 48% (18,230) from eICU, 2% Asian (892), 11% Black (4,289), 5% Hispanic (1,964), and 81% white (31,923). Invasive ventilation occurred in 3,511 (9.2%), and 2,869 (7.5%) died. The rate of invasive ventilation was lower in Asian (HR 0.82, CrI 0.70 to 0.95), Black (HR 0.78, CrI 0.71 to 0.86), and Hispanic (HR 0.70, CrI 0.61 to 0.79) patients as compared to white patients. For the average patient, lower rates of invasive ventilation did not mediate differences in survival. For a reference patient with inspired oxygen (FiO2) varied from 0.5 to 1.0, the change in survival mediated by lower rates of invasive ventilation ranged from probable benefit (probability 0.82 for Asian patients, 0.91 for Black patients, and 0.93 for Hispanic patients) at FiO2 0.5 to probable harm (probability 0.87 for Asian patients, 0.92 for Black patients, and 0.97 for Hispanic patients) at FiO2 1.0, although the mean absolute changes in mortality were all less than 1.5%. ConclusionsAsian, Black, and Hispanic patients had a lower rate of invasive ventilation than white patients. The changes in 28-day survival mediated by this difference ranged from slight benefit at lower inspired oxygen fractions to slight harm at inspired oxygen fraction of 1.0, and there was no difference in survival for the average patient. Key PointsO_ST_ABSQuestionC_ST_ABSWhat is the association between patient race/ethnicity and the use of invasive ventilation in hypoxemic respiratory failure, and what is the impact of any differences on survival? FindingsWe studied 38,263 patients from two US databases, who were 2% Asian (892), 11% Black (4,289), 5% Hispanic (1,964), and 81% white (31,118). Invasive ventilation occurred in 3,511 (9.2%), and 2,869 (7.5%) died. The hazard ratio (HR) for invasive ventilation was lower in Asian (HR 0.82, CrI 0.70 to 0.95), Black (HR 0.78, CrI 0.71 to 0.86), and Hispanic (HR 0.70, CrI 0.61 to 0.79) patients as compared to white patients. For the average patient, race/ethnicity differences in invasive ventilation rates did not mediate differences in 28-day survival. For the reference patient, at inspired oxygen fractions up to 0.9, lower invasive ventilation rates mediated a modest survival benefit, whereas at inspired oxygen fraction of 1.0, the lower invasive ventilation rates mediated a modest survival decrease, although the absolute changes were all less than 1.5%. MeaningAsian, Black, and Hispanic patients had a lower rate of invasive ventilation than white patients. Although this difference had no impact on 28-day survival for the average patient, the change in survival mediated by lower rates of invasive ventilation could range from slight benefit at lower inspired oxygen fractions to slight harm at inspired oxygen fraction of 1.0.

BackgroundICU readmissions are associated with increased morbidity, mortality, and healthcare costs. As ICU patient complexity increases and care practices evolve, the contemporary epidemiology of ICU readmissions remains unclear. We aimed to examine ICU readmission rates and timing across multiple health systems, focusing on unplanned readmissions occurring within 24, 48, and 72 hours after ICU discharge. MethodsWe performed a retrospective cohort study using federated data from the Common Longitudinal ICU data Format (CLIF) Consortium, comprising nine healthcare systems between January 2020 and December 2021 and the MIMIC-IV database. The cohort included adult patients ([&ge;]18 years) discharged alive from the ICU. Readmissions following planned surgeries or interventional procedures were excluded. Data were analyzed locally at each site without centralizing patient-level data, and analyses focused on patient demographics, discharge disposition, readmission timing, and clinical interventions during ICU stays and readmissions. Statistical comparisons were performed using two-proportion z-tests and chi-squared tests. ResultsAmong 185,241 hospital admissions across 19 hospitals, 8.6% of ICU discharges were readmitted during the same hospitalization. Unplanned readmissions occurred within 24 hours in 1.9% of cases, 3.4% within 48 hours, and 4.5% within 72 hours. Readmitted patients experienced higher in-hospital mortality (20.6% vs. 2.1%, p<0.001). Compared to the initial ICU stay, ICU readmissions were associated with significantly increased respiratory (42.3% vs. 35.3%, p<0.001) and vasopressor support (26.1% vs. 23.1%, p<0.001). ConclusionsICU readmissions remain common and are linked to worse outcomes. Readmissions require more respiratory and vasopressor support. Future work should focus on characterizing these subphenotypes and improving ICU discharge processes to reduce preventable readmissions.

PurposeIntensive care unit (ICU) strain is associated with increased mortality. Most strain metrics focus on simple measures such as bed occupancy or admission rates. There is limited data on mitigation strategies, such as procedure teams or staff well-being services on strain, or the impact of increased patient-to-nurse ratios and non-ICU trained nurses working in ICU. MethodsUsing the multi-national UNITE-COVID study, collecting data from ICUs on their busiest day in two periods (2020 and 2021) of the COVID-19 pandemic, we evaluated metrics of strain (Bed occupancy, patient: nurse ratio, use of non-ICU staff and shortages of consumables) and potential mitigators (procedural support teams and staff well-being interventions). We examined how these related to outcomes (mortality, complications and length of stay). ResultsIn both epochs, ICUs experienced significant strain, with ICU bed expansion to 133% and 163% respectively, whilst patient-to-nurse ratios increased by 0.4 and 0.3. Consumable shortages were widespread in 2020. Mortality was inversely correlated with staff well-being interventions in both epochs. Complications were inversely correlated with procedure support teams, and positively correlated with staffing ratios. In regression models, pressure sores were reduced in presence of support teams (p=0.004) and increased with the increase in patients per nurse (p=0.05) whilst unplanned extubations were related to non-ICU trained staff working in ICU(p = 0.02). ConclusionsCOVID-19 induced ICU strain had effects beyond mortality, including increases in complications. Staff pressure and lack of ICU training were related to specific complications, whilst support teams and well-being interventions were associated with improved outcomes. Take home messageWe examined the effects of various aspects of ICU strain on patient outcomes during the periods of maximal unit occupancy during the COVID-19 pandemic. We identified adverse relationships between preventable complications and increases in patient:nursing ratios and use of non-ICU trained staff, whilst procedural support teams and staff well-being interventions were associated with better patient outcomes. summaryCOVID strained ICUs. Increased patient:staff ratios & non-ICU staff increased complications, staff well-being initiatives improved outcomes.

ImportanceDelay in transfer to Intensive Care Unit (ICU) is associated with known adverse clinical and economic outcomes. There are several early warning systems (EWS) that help identify patients that could benefit from earlier ICU transfer but are fraught with challenges when used to measure delays. An objective time stamped blood test metric, such as a blood gas analysis (BGA), could be a valuable adjunct in identifying patients and measuring delays in who require intrahospital transfer to the ICU. BackgroundDelays in transferring critically ill patients to the ICU are linked to increased mortality, organ failure, prolonged recovery, and higher hospital costs. While EWS systems like MEWS, NEWS2, and eCART aim to detect deterioration using vital signs and medical data, they often rely on intermittent and/or subjective inputs. Despite advances, including AI-driven models, most systems still lack accuracy to detect and quantify transfer delays, an important operational metric. ObjectiveThis review explores the clinical and operational impact of ICU transfer delays and evaluates the potential role of BGA as an objective, time-stamped adjunct biomarker for early identification of high-risk patients. We also assess whether BGA could be integrated into EWS tools to enhance predictive accuracy. MethodsWe conducted a systematic literature review of studies published between 1994 and 2024 using PubMed, EMBASE, Cochrane, and NIH databases. Inclusion criteria focused on studies that examined ICU transfer delays, BGA parameters (e.g., lactate, pH, base excess), and clinical outcomes in adult or pediatric patients. Studies were excluded if they had small sample sizes (n < 50), lacked outcome data, or were not published in English. ResultsThe review found that delays in ICU transfer are consistently linked to worse clinical outcomes and higher healthcare costs. While EWS tools have improved early recognition of patient deterioration, they still lack objective, time-stamped markers to measure delays. Approximately one-third of the included studies specifically examined BGA parameters in relation to ICU transfer or outcomes. Elevated lactate levels and abnormal pH values correlated with increased ICU admission, adverse prognosis and mortality risk. Despite this, BGA is not currently integrated into most clinical decision-making tools used for ICU triage. ConclusionBGA represents a promising, underutilized tool that could fill a critical gap in current ICU triage systems. As a time-stamped, objective measure of physiological instability, BGA could enhance the accuracy, timeliness and measurability of ICU transfer decisions--especially when combined with electronic medical records and modern EWS platforms. Future research should focus on evaluating BGA as a predictive input within next-generation EWS tools, with the goal of reducing ICU transfer delays, improving patient outcomes, and optimizing hospital resource use.

There is paucity of evidence related to mechanical ventilation in the general ward setting. We aimed to study the clinico-etiological profile, outcomes and prognostic factors of patients receiving invasive mechanical ventilation in non-ICU (ward) setting, and compare these parameters with that of patients in the ICU, wherever it was reported. A systematic review and meta-analysis was done on articles published till June 2020. Two authors independently extracted the data. The study population included patients who received mechanical ventilation in ward setting. Fourteen studies reporting on 20833 patients were included (20252 exclusively ventilated in ward), with most of the studies being from Israel, USA, Japan and Taiwan. Risk of bias was estimated using the Newcastle-Ottawa Scale for observational studies, and was found to be low. Most common reason for intubation was respiratory illness. Most common variables predicting mortality were prognostic scores like APACHE-II and Acute Physiology Score (APS). Pooled mortality rate in ward across 6 studies was 0.72 (95% CI 0.69-0.74) with no heterogeneity among these 6 studies (I2=0.0). Mortality rate varied significantly with study population characteristics, and was lower among patients being weaned in ward. A major limitation of our study was the paucity of studies and significant heterogeneity among existing studies, with respect to outcomes like duration of ventilation, hospital stay, rates of complications, and prognostic factors. This systematic review and meta-analysis found that mortality among patients receiving invasive mechanical ventilation in ward settings remains high. Data regarding other outcomes and prognostic factors predicting mortality was very heterogeneous highlighting the need for future studies concentrating specifically on these aspects. Systematic review registration: PROSPERO 2020 (CRD42020166775)

ImportanceTrauma quality improvement programs relies on peer review of patient cases to identify opportunities for improvement. Current state-of-the-art systems for selecting patient cases for peer review use audit filters that struggle with poor performance. ObjectiveTo develop models predicting opportunities for improvement in trauma care and compare their performance to currently used audit filters. Design, Setting and ParticipantsThis single-center registry-based cohort study used data from the trauma centre at Karolinska University Hospital in Stockholm, Sweden, between 2013 and 2023. Participants were adult trauma patients included in the local trauma registry. The models predicting opportunities for improvement in trauma care were developed using logistic regression and the eXtreme Gradient Boosting learner (XGBoost) with an add-one-year-in expanding window approach. Performance was measured using the integrated calibration index (ICI), area under the receiver operating curve (AUC), true positive rates (TPR) and false positive rates (FPR). We compared the performance of the models to locally used audit filters. Main outcome measureOpportunities for improvement, defined as preventable events in patient care with adverse outcomes. These opportunities for improvement were identified by the local peer review processes. ResultsA total of 8,220 patients were included. The mean (SD) age was 45 (21), 5696 patients (69%) were male, and the mean (SD) injury severity score was 12 (13). Opportunities for improvement were identified in 496 (6%) patients. The logistic regression and XGBoost models were well calibrated with ICIs (95% CI) of 0.032 (0.032-0.032) and 0.033 (0.032-0.033). Compared to the audit filters, both the logistic regression and XGBoost models had higher AUCs (95% CI) of 0.72 (0.717-0.723) and 0.75 (0.747-0.753), TPR (95% CI) of 0.885 (0.881-0.888) and 0.904 (0.901-0.907), and lower FPR (95% CI) of 0.636 (0.635-0.638) and 0.599 (0.598-0.6). The audit filters had an AUC (95% CI) of 0.616 (0.614-0.618), a TPR (95% CI) of 0.903 (0.9-0.906), and a FPR (95% CI) of 0.671 (0.67-0.672). Conclusion and RelevanceBoth the logistic regression and XGBoost models outperformed audit filters in predicting opportunities for improvement among adult trauma patients and can potentially be used to improve systems for selecting patient cases for trauma peer review. Key pointQuestion: How does the performance of machine learning models compare to audit filters when screening for opportunities for improvement, preventable events in care with adverse outcomes, among adult trauma patients? Findings: Our registry-based cohort study including 8,220 patients showed that machine learning models outperform audit filters, with improved discrimination and false-positive rates. Compared to audit filters, these models can be configurated to balance sensitivity against overall screening burden. Meaning: Machine learning models have the potential to reduce false positives when screening for opportunities for improvement in the care of adult trauma patients and thereby enhancing trauma quality improvement programs.

RationalePatients receiving prolonged mechanical ventilation are often discharged to long-term acute care hospitals (LTACHs) with hopes of recovery and ultimately return to the community. Among those who survive and undergo tracheostomy, little is known about their quality of life and social outcomes after LTACH discharge. ObjectiveMeasure health related quality of life in a cohort of critical illness survivors who underwent tracheostomy and an LTACH stay MethodsSingle center, prospective observational cohort study conducted at a long-term acute care hospital between 2022-2024. Adults with prolonged mechanical ventilation requiring tracheostomy were eligible. Survivors or surrogates completed a telephone survey 3-6 months after LTACH admission. Surveys included the Katz Index of Independence in Activities of Daily Living (ADL) and Patient-Reported Outcome Measurement Information System (PROMIS) measures of physical, mental, and social health. Descriptive statistics summarized scores; exploratory analyses examined associations between persistent tracheostomy and residence. ResultsSeventy participants were enrolled (median age 64 years; 58.6% male). Median ICU length of stay was 40 days prior to LTACH transfer. By LTACH discharge, 39 people (56%) had been decannulated. At a median follow-up of 5.5 months, 50 participants (71%) were alive, 39 completed the survey. Most respondents reported impairments in feeding, dressing, and bathing. PROMIS t-scores demonstrated severe impairments in physical function (median 26.7), and ability to participate in social roles (37.0), with high symptom burden of depression (61.9) and anxiety (58.3). Greater impairment was observed among participants with ongoing tracheostomy or were not residing at home. Home residence did not differ significantly by decannulation status (61.8% decannulated vs. 46.7% not decannulated; OR 1.85 (95% CI 0.54, 6.30)). ConclusionsSurvivors of PMV and LTACH admission experience marked functional impairments, restricted participation in social roles, and prominent symptoms of depression and anxiety--particularly among patients not living at home or with persistent tracheostomy. These data may help clinicians prepare patients and families for life after tracheostomy and guide tailored support addressing multifaceted needs. Primary Funding SourceNational Institutes of Health