Current opinion in critical care
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Curr Opin Crit Care · Aug 2023
ReviewCardiogenic shock: a major challenge for the clinical trialist.
Cardiogenic shock (CS) results in persistently high short-term mortality and a lack of evidence-based therapies. Several trials of novel interventions have failed to show an improvement in clinical outcomes despite promising preclinical and physiologic principles. In this review, we highlight the challenges of CS trials and provide suggestions for the optimization and harmonization of their design. ⋯ Accurate characterization of CS severity and its pathophysiology are crucial to unravel heterogeneity and identify the patients most likely to benefit from a tested treatment. Implementation of biomarker-stratified adaptive clinical trial designs (i.e., biomarker or subphenotype-based therapy) might provide important insights into treatment effects.
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Curr Opin Crit Care · Aug 2023
ReviewThe changing face of cardiogenic shock: definitions, epidemiology, and severity assessment.
Cardiogenic shock (CS) has been recognized for >50 years, most commonly in the setting of myocardial infarction. This review covers recent advances in the definitions, epidemiology and severity assessment of cardiogenic shock. ⋯ Cardiogenic shock mortality has not changed in a significant way in many years. Recent advances such as more granular assessment of shock severity have the potential to improve outcomes by allowing research to separate the patient groups which may respond differently to various therapies.
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Curr Opin Crit Care · Aug 2023
ReviewInsulin resistance in critical illness: consequences for nutrition therapy and glucose management.
Critically ill patients usually develop insulin resistance and hyperglycemia, which is aggravated by early parenteral nutrition. In observational studies, the lowest mortality risk associates with glucose concentrations close to the antecedent average glucose level. This review summarizes the most recent evidence regarding glucose control in critical illness. ⋯ It remains unclear whether tight glucose control in critical illness is beneficial or not in the absence of early parenteral nutrition, which is currently being studied in the multicenter TGC-fast randomized controlled trial. Without new evidence, it seems prudent to avoid severe hyperglycemia and hypoglycemia in all patients.
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This review will focus on the neglected side of metabolic support in ICU survivors: nutritional therapy after critical illness. Knowledge of the evolution of the metabolism of patients that survived critical illness will be bundled, and current practices will be investigated. We will discuss some studies conducted to determine resting energy expenditure in ICU survivors and which identified barriers that cause interruptions in the feeding process based on published data between January 2022 and April 2023. ⋯ Patients may be in a catabolic state during and after ICU discharge, with several factors impacting metabolism. Therefore, large prospective trials are needed to determine the physiological state of ICU survivors, determine nutritional requirements, and develop nutritional care protocols. Many barriers causing decreased feeding adequacy have already been identified, but solutions are scarce. This review depicts a variable metabolic rate among ICU survivors and a significant variation in feeding adequacy in-between world regions, institutions, and patient sub-phenotypes.
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Numerous micronutrients are involved in antioxidant and immune defence, while their blood concentrations are frequently low in critically ill patients: this has fuelled many supplementation trials. Numerous observational, randomized studies have been published, which are presented herein. ⋯ The needs in critical illness are higher than those of healthy individuals and must be covered to support immunity. Monitoring selected micronutrients is justified in patients requiring more prolonged ICU therapy. Actual results point towards combinations of essential micronutrients at doses below upper tolerable levels. Finally, the time of high-dose micronutrient monotherapy is probably over.