期刊题录 -- 2022 Current Opinion In Critical Care

# 期刊题录 -- 2022 Current Opinion In Critical Care

Atman 机器翻译，未校对

# Staffing models in the cardiac intensive care unit.

Author: Mary Quien, Alexander Thomas, Jonathan Ludmir, P. Miller

Abstract: Purpose of review: The modern cardiac intensive care unit (CICU) has evolved into a high-intensity unit that cares for critically ill patients. Despite this transformation, changes to the staffing model and organizational structure in these specialized units have only recently begun to meet these challenges. We describe the most recent evidence which will inform future CICU staffing models.

Recent findings: In the United States, the majority of CICUs are open as opposed to closed units, yet recent data suggests that transition to a closed staffing model is associated with a decrease in mortality. These reductions in mortality in closed CICUs are most pronounced in the most critically ill populations, such as patients with mechanical circulatory support, cardiac arrest, and respiratory failure. In addition, one study has shown that transition to a cardiac intensivist staffed CICU was associated with a reduction in mortality. Finally, multidisciplinary and protocolized teams imbedded within the CICU, specifically 'shock teams,' have recently been developed and may reduce mortality in this particularly sick patient population.

Summary: Although the preponderance of data suggests improved outcomes with a closed, intensivist staffed CICU model, future multicenter studies are needed to better define the ideal staffing models for the contemporary CICU.

# 心脏重症监护室的人员配备模型。

综述目的：现代心脏重症监护室 (CICU) 已经演变为护理危重患者的高强度病房。尽管发生了这种转变，但这些专业单位的人员配备模式和组织结构的变化最近才开始应对这些挑战。我们描述了最新的证据，这些证据将为未来的 CICU 人员配备模式提供信息。

最近的结果：在美国，大多数 CICU 是开放的，而不是关闭的病房，但是最近的数据表明，转变为关闭的人员配备模式与死亡率降低相关。在关闭的 CICU 中，这些死亡率下降在最危重人群中最明显，例如机械循环支持、心脏骤停和呼吸衰竭患者。此外，一项研究显示，转为心脏重症监护医生 (CICU) 可降低死亡率。最后，最近开发了嵌入 CICU 的多学科和方案化团队，尤其是 “休克团队”，可能降低该特殊患病患者人群的死亡率。

总结：尽管数据的优势表明，采用封闭的重症监护医生工作人员 CICU 模型可改善结局，但仍需要进一步的多中心研究来更好地确定当前 CICU 的理想人员配备模型。

期：4 ；页码：453-459； DOI：10.1097/MCC.0000000000000958

# Outcomes in cardiogenic shock: the role of surrogate endpoints.

Author: Leah Kosyakovsky, Jeffrey Marbach, Khoa Nguyen, Srini Mukundan, Haval Chweich, Navin Kapur

Abstract: Purpose of review: Early revascularization, invasive hemodynamic profiling, and initiation of temporary mechanical circulatory support (MCS) have all become routine components of cardiogenic shock (CS) management. Despite this evolution in clinical practice, patient selection and timing of treatment initiation remain a significant barrier to achieving sustained improvement in CS outcomes. Recent efforts to standardize CS management, through the development of treatment algorithms, have relied heavily on surrogate endpoints to drive therapeutic decisions. The present review aims to provide an overview of the basis of evidence for those surrogate endpoints commonly employed in clinical trials and CS management algorithms.

Recent findings: Recent publications from both observational and randomized cohorts have demonstrated the utility of surrogate endpoints in risk stratifying patients with CS. In particular, invasive hemodynamics using pulmonary artery catheters to guide initiation and weaning of MCS, biochemical markers that portend imminent end-organ failure, and clinical risk scores that combine multiple hemodynamic and laboratory parameters have demonstrated an ability to prognosticate outcomes in patients with CS.

Summary: Although further validation is necessary, multiple clinical, hemodynamic, and biochemical markers have demonstrated utility as surrogate endpoints in CS, and will undoubtedly assist physicians in clinical decision-making.

# 心源性休克的结局：替代终点的作用。

综述目的：早期血运重建、侵入性血液动力学特征和开始临时机械循环支持 (MCS) 均已成为心源性休克 (CS) 管理的常规组成部分。尽管在临床实践中不断取得进展，但患者选择和治疗开始的时机仍是实现 CS 结局持续改善的重要障碍。通过治疗算法的开发，近期标准化 CS 管理的努力在很大程度上依赖于替代终点来驱动治疗决策。本综述旨在对临床试验常用的替代终点和 CS 管理算法的证据基础进行综述。

近期结果：来自观察性和随机化队列的近期出版物已证实替代终点在对 CS 患者进行风险分层中的效用。尤其是，使用肺动脉导管指导 MCS 启动和撤机的侵入性血液动力学、预示即将发生终末器官衰竭的生化标志物以及结合了多个血液动力学和实验室参数的临床风险评分已证实具有预测 CS 患者结局的能力。

总结：尽管需要进一步验证，但多个临床、血流动力学和生化标志物已证实可作为 CS 的替代终点，无疑将帮助医生做出临床决策。

期：4 ；页码：442-452； DOI：10.1097/MCC.0000000000000963

# Mechanical circulatory support in the treatment of cardiogenic shock.

Author: Shannon Fernando, Susanna Price, Rebecca Mathew, Arthur Slutsky, Alain Combes, Daniel Brodie

Abstract: Purpose of review: Cardiogenic shock is a condition that is characterized by end-organ hypoperfusion secondary to reduced cardiac output, and is associated with substantial mortality. The mainstay of therapy for cardiogenic shock is reversal of the underlying cause, and concomitant supportive care with vasoactive medications (vasopressors and inotropes). Patients who continue to deteriorate despite these measures may require mechanical circulatory support (MCS). Here, we review the devices available for MCS, and their associated benefits and risks.

Recent findings: Despite growing use worldwide, there is little randomized evidence supporting the routine use of any specific device for MCS in cardiogenic shock. A large randomized trial of the intra-aortic balloon pump did not demonstrate short- or long-term improvement in mortality. The TandemHeart and Impella devices which assist in left ventricular unloading have only been evaluated in small randomized trials, which showed an increase in adverse events without improvement in mortality. Finally, venoarterial extracorporeal membrane oxygenation (provides both circulatory and respiratory support) and is currently being evaluated in large randomized clinical trials.

Summary: Various devices for MCS in cardiogenic shock are available, but routine use is not supported by high-quality randomized evidence. Given the resources required for initiation of MCS, use of these treatments should be limited to centers experienced in advanced cardiac care, and future research should focus on what role (if any) these devices have in clinical practice.

# 机械循环支持治疗心源性休克。

综述目的：心源性休克是一种以继发于心输出量减少的终末器官灌注不足为特征的疾病，与实质性死亡率相关。心源性休克的主要治疗方法是逆转基础病因，同时给予血管活性药物（血管加压药和正性肌力药）支持治疗。尽管采用了这些措施仍继续恶化的患者可能需要机械循环支持 (MCS)。在此，我们对可用于 MCS 的器械及其相关获益和风险进行了审查。

最近的结果：尽管在全球范围内的使用越来越多，但很少有随机证据支持在心源性休克中常规使用任何 MCS 特定器械。主动脉内球囊反搏的一项大型随机试验未显示死亡率的短期或长期改善。仅在小型随机试验中评价了协助左心室卸载的 TandemHeart 和 Impella 器械，这些试验显示不良事件增加，而死亡率未改善。最后，静脉 - 动脉体外膜肺氧合（提供循环和呼吸支持），目前正在大型随机化临床试验中进行评价。

总结：MCS 在心源性休克中的各种器械均可用，但高质量随机证据不支持常规使用。考虑到启动 MCS 所需的资源，这些治疗应仅限于具有心脏护理经验的中心，未来的研究应重点关注这些器械在临床实践中的作用（如果有）。

期：4 ；页码：434-441； DOI：10.1097/MCC.0000000000000956

# Transcatheter edge-to-edge repair in patients with mitral regurgitation and cardiogenic shock: a new therapeutic target.

Author: Richard Jung, Trevor Simard, Pietro Di Santo, Benjamin Hibbert

Abstract: Purpose of review: Cardiogenic shock with significant mitral regurgitation portends a poor prognosis with limited therapeutic options. Herein, we review the available evidence regarding the patient characteristics, management, impact of transcatheter edge-to-edge repair (TEER) on hemodynamics, and clinical outcomes of patients with cardiogenic shock and mitral regurgitation.

Recent findings: Several observational studies and systematic reviews have demonstrated the feasibility and safety of TEER in cardiogenic shock complicated by degenerative or functional mitral regurgitation. Surgical interventions for mitral regurgitation remain limited owing to the risk profile of patients in cardiogenic shock. TEER has been studied in both degenerative and functional mitral regurgitation and remains feasible in the critically ill population. Moreover, TEER is associated with reduction in mitral regurgitation and improvement in-hospital and long-term mortality.

Summary: TEER remains a promising therapeutic option in cardiogenic shock complicated by significant mitral regurgitation, but additional research is required to identify patient and procedural characteristics, hemodynamic parameters, and the optimal time for intervention. Moreover, future randomized controlled trials are in progress to evaluate the potential benefit of TEER against medical management in cardiogenic shock and mitral regurgitation.

# 二尖瓣反流和心源性休克患者的经导管缘对缘修复：一个新的治疗目标。

综述目的：心源性休克伴明显二尖瓣返流提示预后较差，治疗选择有限。在此，我们回顾了有关心源性休克和二尖瓣返流患者的特征、管理、经导管边缘修复术 (TEER) 对血流动力学的影响以及临床结局的现有证据。

近期结果：几项观察性研究和系统综述证实了 TEER 在并发退行性或功能性二尖瓣返流的心源性休克中的可行性和安全性。由于心源性休克患者的风险特征，二尖瓣返流的手术干预仍然有限。在退行性和功能性二尖瓣返流患者中对 TEER 进行了研究，TEER 在重症人群中仍然可行。此外，TEER 与二尖瓣反流减少以及住院和长期死亡率改善相关。

总结：TEER 仍是心源性休克并发严重二尖瓣返流的一种有前景的治疗选择，但需要额外的研究来确定患者和手术特征、血液动力学参数和最佳介入时间。此外，未来的随机对照试验正在进行中，以评价 TEER 相对于心源性休克和二尖瓣返流医学管理的潜在获益。

期：4 ；页码：426-433； DOI：10.1097/MCC.0000000000000952

# Inotrope and vasopressor use in cardiogenic shock: what, when and why?.

Author: Kira Hu, Rebecca Mathew

Abstract: Purpose of review: Despite increasing interest in the management of cardiogenic shock (CS), mortality rates remain unacceptably high. The mainstay of supportive treatment includes vasopressors and inotropes. These medications are recommended in international guidelines and are widely used despite limited evidence supporting safety and efficacy in CS.

Recent findings: The OptimaCC trial further supports that norepinephrine should continue to be the first-line vasopressor of choice in CS. The CAPITAL DOREMI trial found that milrinone is not superior to dobutamine in reducing morbidity and mortality in CS. Two studies currently underway will offer the first evidence of the necessity of inotrope therapy in placebo-controlled trials: CAPITAL DOREMI2 will randomize CS patients to inotrope or placebo in the initial resuscitation of shock to evaluate the efficacy of inotrope therapy and LevoHeartShock will examine the efficacy of levosimendan against placebo in early CS requiring vasopressor therapy.

Summary: Review of the current literature fails to show significant mortality benefit with any specific vasopressor or inotropic in CS patients. The upcoming DOREMI 2 and levosimendan versus placebo trials will further tackle the question of inotrope necessity in CS. At this time, inotrope selection should be guided by physician experience, availability, cost, and most importantly, individual patients' response to therapy.

# 心源性休克的正性肌力药和血管加压药使用：什么时候、什么原因？

综述目的：尽管人们对心源性休克 (CS) 的治疗越来越感兴趣，但死亡率仍然高得令人无法接受。支持性治疗的主要内容包括血管加压药和正性肌力药物。这些药物在国际指南中被推荐，尽管支持 CS 安全性和疗效的证据有限，但被广泛使用。 最新结果：OptimaCC 试验进一步支持去甲肾上腺素应继续作为 CS 的一线血管加压素选择。CAPITAL DOREMI 试验发现，米力农在降低 CS 发病率和死亡率方面并不优于多巴酚丁胺。目前正在进行的两项研究将提供安慰剂对照试验中强心剂治疗必要性的首个证据：CAPITAL DOREMI2 将在休克初始复苏时将 CS 患者随机分配至强心剂组或安慰剂组，以评价强心剂治疗的有效性；LevoHeartShock 将检查左西孟旦对比安慰剂在早期治疗需要升压治疗的 CS 的有效性。

总结：当前文献综述未显示任何特定血管加压药或正性肌力药物在 CS 患者中的显著死亡率获益。即将进行的 DOREMI 2 和左西孟旦对比安慰剂试验将进一步解决皮质内固醇中强心剂必要性的问题。此时，应根据医生的经验、可用性、费用以及最重要的是个体患者对治疗的反应来选择正性肌力药物。

期：4 ；页码：419-425； DOI：10.1097/MCC.0000000000000957

# Editorial: Idolatry in cardiogenic shock: are we coming to a state of emergence.

Author: Benjamin Hibbert

# 社论：心源性休克的 Idolatry：我们正处于一种新的状态。

期：4 ；页码：417-418； DOI：10.1097/MCC.0000000000000954

# Poor physical recovery after critical illness: incidence, features, risk factors, pathophysiology, and evidence-based therapies.

Author: Yente Boelens, Max Melchers, Arthur van Zanten

Abstract: Purpose of review: To summarize the incidence, features, pathogenesis, risk factors, and evidence-based therapies of prolonged intensive care unit (ICU) acquired weakness (ICU-AW). We aim to provide an updated overview on aspects of poor physical recovery following critical illness.

Recent findings: New physical problems after ICU survival, such as muscle weakness, weakened condition, and reduced exercise capacity, are the most frequently encountered limitations of patients with postintensive care syndrome. Disabilities may persist for months to years and frequently do not fully recover. Hormonal and mitochondrial disturbances, impaired muscle regeneration due to injured satellite cells and epigenetic differences may be involved in sustained ICU-AW. Although demographics and ICU treatment factors appear essential determinants for physical recovery, pre-ICU health status is also crucial. Currently, no effective treatments are available. Early mobilization in the ICU may improve physical outcomes at ICU-discharge, but there is no evidence for benefit on long-term physical recovery.

Summary: Impaired physical recovery is observed frequently among ICU survivors. The pre-ICU health status, demographic, and ICU treatment factors appear to be important determinants for physical convalescence during the post-ICU phase. The pathophysiological mechanisms involved are poorly understood, thereby resulting in exiguous evidence-based treatment strategies to date.

# 危重病后身体恢复较差：发生率、特征、风险因素、病理生理学和循证治疗。

综述目的：总结长期重症监护病房 (ICU) 获得性虚弱 (ICU-AW) 的发生率、特征、发病机制、风险因素和循证疗法。我们旨在提供危重病后身体恢复较差方面的更新概述。

近期结果：ICU 存活后出现的新的身体问题，如肌无力、身体虚弱和运动能力下降，是重症监护后综合征患者最常遇到的局限性。残疾可能持续数月至数年，通常无法完全恢复。激素和线粒体紊乱、卫星细胞损伤导致的肌肉再生障碍和表观遗传差异可能参与了持续的 ICU-AW。虽然人口统计学和 ICU 治疗因素似乎对身体恢复至关重要，但 ICU 前的健康状况也很重要。目前尚无有效的治疗方法。ICU 中的早期活动可能改善出院时的身体结局，但无证据表明长期身体恢复可带来获益。

总结：在 ICU 存活者中经常观察到身体恢复受损。ICU 前健康状况、人口统计学和 ICU 治疗因素似乎是 ICU 后期身体康复的重要决定因素。对其中涉及的病理生理机制知之甚少，从而导致迄今为止令人费解的循证治疗策略。

期：4 ；页码：409-416； DOI：10.1097/MCC.0000000000000955

# Challenges and advances in nutrition for the critically ill child.

Author: Ben Albert, Enid Martinez

Abstract: Purpose of review: Malnutrition remains prevalent in critically ill children and is associated with worse clinical outcomes. Conversely, nutrition provision has been associated with improved survival. Nutritional challenges must be addressed to guide best nutrition practices for the critically ill child. In this narrative review, we summarize findings from research published between July 2020 and January 2022 on nutrition in critically ill children. Findings from these articles build on previous work to guide next steps in both research and clinical practice in this cohort.

Recent findings: A comprehensive literature review was performed. We identified the following common themes for research published between July 2020 and January 2022-metabolism, enteral nutrition, including timing, dosing, protein prescription and delivery in special populations, gastrointestinal function, and enteral nutrition adjunctive therapies.

Summary: Research continues to support early initiation and advancement of enteral nutrition. Achieving nutritional adequacy is challenging, but research associated with the timing and dosing of enteral nutrition, alternative methods of enteral nutrition delivery and the use of adjuncts are expanding our understanding of best practices for this cohort. Areas for further research continue to be the use of measured energy requirements, protein dosing and inclusion of functional outcomes to assess the benefit of nutritional interventions.

# 危重患儿营养的挑战与进展。

审查目的：营养不良在重症儿童中仍很普遍，并且与较差的临床结局相关。相反，提供营养与改善生存率相关。必须解决营养挑战，以指导危重儿童的最佳营养实践。在本叙述性综述中，我们总结了 2020 年 7 月至 2022 年 1 月期间发表的关于危重儿童营养的研究结果。这些文章的结果以之前的工作为基础，指导本队列研究和临床实践的后续步骤。

近期结果：进行了全面的文献综述。我们确定了 2020 年 7 月至 2022 年 1 月期间发表的研究的以下共同主题：代谢、肠内营养，包括时间、剂量、特殊人群的蛋白质处方和递送、胃肠功能和肠内营养辅助治疗。

总结：研究继续支持早期开始和推进肠内营养。实现营养充分性具有挑战性，但与肠内营养的时间和剂量、肠内营养输送的替代方法和辅助药物使用相关的研究正在扩展我们对该队列最佳实践的理解。进一步研究的领域仍然是使用测量的能量需求、蛋白质剂量和纳入功能性结局，以评估营养干预的获益。

期：4 ；页码：401-408； DOI：10.1097/MCC.0000000000000953

# Nutrition before, during and after critical illness.

Author: Emma Ridley, Kate Lambell

Abstract: Purpose of review: This review describes considerations preintensive care unit (ICU), within ICU and in the post-ICU period regarding nutrition management and the current state of the literature base informing clinical care.

Recent findings: Within ICU, studies have focussed on the first 5-7 days of illness in mechanically ventilated patients who are heterogeneous and with minimal consideration to premorbid nutrition state. Many evidence gaps in the period within ICU remain, with the major ones being the amount of protein to provide and the impact of longer-term nutrition interventions. Personalised nutrition and nutrition in the post-ICU period are becoming key areas of focus.

Summary: Nutrition for the critically ill patient should not be viewed in isolated time periods; what happens before, during and after ICU is likely important to the overall recovery trajectory. It is critical that the impact of nutrition on clinical and functional outcomes across hospitalisation is investigated in specific groups and using interventions in ways that are biologically plausible to impact. Areas that show promise for the future of critical care nutrition include interventions delivered for a longer duration and inclusion of oral nutrition support, individualised nutrition regimes, and use of emerging bedside body composition techniques to identify patients at nutritional risk.

# 危重病前、中、后的营养。

综述目的：本综述描述了重症监护室 (ICU) 前、ICU 内和 ICU 后期间关于营养管理的注意事项和提供临床护理信息的文献库的现状。

近期结果：在 ICU 内，研究重点关注病情不稳定的机械通气患者发病前 5-7 天的营养状态。ICU 内的这段时间仍存在许多证据空白，主要是提供的蛋白质量和长期营养干预的影响。ICU 后期的个体化营养和营养正成为重点关注的领域。

总结：不应在孤立的时间段内观察危重患者的营养情况；在 ICU 之前、期间和之后发生的情况可能对整体恢复轨迹很重要。关键是在特定人群中研究住院期间营养对临床和功能结局的影响，并以生物学上合理影响的方式使用干预措施。显示出对未来重症监护营养有希望的领域包括干预持续时间更长，并包括口服营养支持、个体化营养方案和使用新的床旁身体组成技术来识别有营养风险的患者。

期：4 ；页码：395-400； DOI：10.1097/MCC.0000000000000961

# Update on glucose control during and after critical illness.

Author: Adam Deane, Mark Plummer, Yasmine Ali Abdelhamid

Abstract: Purpose of review: There is a complex bidirectional relationship between critical illness and disordered glucose metabolism. This review aims to provide a comprehensive summary of the recent evidence focused on the relationship between critical illness and disordered glucose metabolism through the distinct phases of prior to, during, and after an acute illness that requires admission to the intensive care unit (ICU).

Recent findings: Recent data suggest that preexisting glucose metabolism affects the optimal blood glucose target during critical illness, with preliminary data suggesting that glucose targets should be 'personalized' based on preexisting glycemia. Because of the close association between critical illness and disordered glucose metabolism, there is a need to optimize glucose monitoring in the ICU with rapid, precise, and cost-efficient measurements at the bedside. Recent studies have evaluated the use of various methodologies, with a focus on the use of near-continuous glucose monitoring. For those patients with preexisting diabetes who survive ICU, nocturnal hypoglycemia may be an unrecognized and important issue when discharged to the ward. There is increasing evidence that patients with high blood glucose during their acute illness, so called 'stress hyperglycemia', are at increased risk of developing diabetes in the years following recovery from the inciting event. Critically ill patients with COVID-19 appear at greater risk.

Summary: There have been important recent insights in the approach to glucose monitoring and glucose targets during critical illness, monitoring and administration of glucose-lowering drugs on discharge from the ICU, and longitudinal follow-up of patients with stress hyperglycemia.

# 危重病期间和之后血糖控制的更新。

综述目的：危重症与糖代谢紊乱之间存在复杂的双向关系。本综述旨在通过需要入住重症监护室 (ICU) 的急性疾病之前、期间和之后的不同阶段，对近期有关危重症与葡萄糖代谢紊乱之间关系的证据进行全面总结。

近期结果：近期数据表明，在危重疾病期间，既存葡萄糖代谢会影响最佳血糖目标，初步数据表明，应根据既存血糖 “个性化” 血糖目标。由于危重症和葡萄糖代谢紊乱之间存在密切关联，因此需要在 ICU 床边通过快速、精确和经济有效的测量来优化血糖监测。近期研究对各种方法的使用进行了评价，重点关注近连续血糖监测的使用。对于那些在 ICU 存活下来的已有糖尿病的患者，夜间低血糖可能是一个未被识别的重要问题，当他们出院进入病房时。越来越多的证据表明，急性疾病期间伴有高血糖（即所谓的 “应激性高血糖”）的患者在从刺激事件中恢复后数年内发生糖尿病的风险升高。COVID-19 重症患者的风险似乎更高。

总结：近期对危重病期间血糖监测方法和血糖目标、离开 ICU 时降糖药物的监测和给药以及应激性高血糖患者的纵向随访有了重要的见解。

期：4 ；页码：389-394； DOI：10.1097/MCC.0000000000000962

# Intermittent feeding and circadian rhythm in critical illness.

Author: Imre Kouw, Leonie Heilbronn, Arthur van Zanten

Abstract: Purpose of review: Circadian rhythms, i.e. periodic oscillations in internal biological processes, modulate metabolic processes such as hormonal signalling, nutrient absorption, and xenobiotic detoxification. Meal timing is a strong entraining cue for peripheral clocks in various organs, and eating out of circadian phases can impair glucose, gastrointestinal, and muscle metabolism. Sleep/wake cycles and circadian rhythms are extremely disrupted during critical illness. Timing of nutritional support may help preserve circadian rhythms and improve post-Intensive Care Unit (ICU) recovery. This review summarises circadian disruptors during ICU admission and evaluates the potential benefits of intermittent feeding on metabolism and circadian rhythms.

Recent findings: Rhythmic expression of core clock genes becomes rapidly disturbed during critical illness and remains disturbed for weeks. Intermittent, bolus, and cyclic enteral feeding have been directly compared to routine continuous feeding, yet no benefits on glycaemic control, gastrointestinal tolerance, and muscle mass have been observed and impacts of circadian clocks remain untested.

Summary: Aligning timing of nutritional intake, physical activity, and/or medication with circadian rhythms are potential strategies to reset peripheral circadian rhythms and may enhance ICU recovery but is not proven beneficial yet. Therefore, selecting intermittent feeding over continuous feeding must be balanced against the pros and cons of clinical practice.

# 危重病间歇喂养与昼夜节律。

综述目的：昼夜节律，即内部生物过程的周期性振荡，调节代谢过程，如激素信号传导、营养吸收和异生物质解毒。进餐时间是各器官外周时钟的强吸引信号，昼夜节律以外的阶段进食会损害葡萄糖、胃肠道和肌肉代谢。危重疾病期间，睡眠 / 觉醒周期和昼夜节律极度紊乱。营养支持的时机可能有助于保持昼夜节律和改善重症监护室 (ICU) 后恢复。这篇综述总结了 ICU 住院期间的昼夜节律紊乱，并评价了间歇喂养对代谢和昼夜节律的潜在益处。最新发现：危重病期间，核心时钟基因的节律性表达迅速紊乱，并持续数周。已将间歇、推注和循环肠内喂养与常规连续喂养直接比较，但未观察到对血糖控制、胃肠道耐受性和肌肉量的益处，昼夜节律钟的影响仍未检测。

总结：调整营养摄入、体力活动和 / 或药物治疗与昼夜节律的时间是重置外周昼夜节律的潜在策略，可能会促进 ICU 恢复，但尚未证实有益。因此，选择间歇喂养而非持续喂养，必须与临床实践的利弊相平衡。

期：4 ；页码：381-388； DOI：10.1097/MCC.0000000000000960

# Update on vitamin C administration in critical illness.

Author: Tomoko Fujii, Yugeesh Lankadeva, Rinaldo Bellomo

Abstract: Purpose of review: Several studies have recently explored the effects of intravenous vitamin C in sepsis. We aimed to summarize their findings to provide perspectives for future research.

Recent findings: Sepsis trials examined 6 g/day of intravenous vitamin C with or without the thiamine and/or hydrocortisone compared with placebo or hydrocortisone. Network meta-analysis reported that intravenous vitamin C, thiamine, hydrocortisone, or combinations of these drugs was not proven to reduce long-term mortality. However, the component network meta-analysis suggested an association of high-dose (>6 g/day) and very-high dose vitamin C (>12 g/day) and decreased mortality but with low certainty. The preclinical investigations have, however, advanced to much higher doses of intravenous vitamin C therapy since a scoping review on harm reported that mega-doses of intravenous vitamin C (50-100 g/day) had been administered without any conclusive adverse effects. In a Gram-negative sheep model, renal tissue hypoperfusion was reversed, followed by improvements in kidney function when a mega-dose of vitamin C (150 g/day equivalent) was administered.

Summary: The effect of intravenous vitamin C in critically ill patients has yet to be determined and might be dose-dependent. Clinical studies of very high or mega doses of vitamin C are justified by preclinical data.

# 危重病患者维生素 C 给药的更新。

综述目的：近期几项研究探索了静脉注射维生素 C 在败血症中的作用。我们旨在总结他们的研究结果，为未来的研究提供视角。

近期结果：败血症试验检查了与安慰剂或氢化可的松相比，静脉注射维生素 C 6g / 天（伴或不伴硫胺素和 / 或氢化可的松）。网络荟萃分析报告，未证实静脉维生素 C、硫胺素、氢化可的松或这些药物的联合给药可降低长期死亡率。然而，组分网络荟萃分析提示高剂量（> 6 g / 天）和极高剂量维生素 C（> 12 g / 天）与死亡率降低相关，但确定性较低。然而，临床前研究已经推进到更高剂量的静脉内维生素 C 治疗，因为一项关于危害的范围审查报告称给予了超大剂量的静脉内维生素 C（50-100 g / 天），没有任何结论性不良反应。在革兰氏阴性绵羊模型中，给予超大剂量维生素 C（150 g / 天当量）后，肾组织灌注不足得到逆转，随后肾功能得到改善。

总结：静脉给予维生素 C 在重症患者中的作用尚未确定，可能具有剂量依赖性。临床前数据证实，对极高或极高剂量维生素 C 进行临床研究是合理的。

期：4 ；页码：374-380； DOI：10.1097/MCC.0000000000000951

# Protein metabolism in critical illness.

Author: Lee-anne Chapple, Rob van Gassel, Olav Rooyackers

Abstract: Purpose of review: Critically ill patients experience skeletal muscle wasting that may contribute to the profound functional deficits in those that survive the initial injury. Augmented protein delivery has the potential to attenuate muscle loss, yet the ability for dietary protein to improve patient outcomes is reliant on effective protein metabolism. This review will discuss the recent literature on protein delivery and digestion, amino acid absorption, and muscle protein synthesis (MPS) in critically ill adults.

Recent findings: Critically ill patients are prescribed protein doses similar to international recommendations, yet actual delivery remains inadequate. The majority of trials that have achieved higher protein doses have observed no effect on muscle mass, strength or function. Critically ill patients have been observed to have minimal deficits in protein digestion and amino acid absorption when delivery bypasses the stomach, yet postprandial MPS is impaired. However, the literature is limited due to the complexities in the direct measurement of protein handling.

Summary: Postprandial MPS is impaired in critically ill patients and may exacerbate muscle wasting experienced by these patients. Studies in critically ill patients require assessment not only of protein delivery, but also utilization prior to implementation of augmented protein doses.

# 危重病患者的蛋白质代谢。

审查目的：重症患者出现骨骼肌消耗，可能导致那些在初始损伤后存活的患者出现明显的功能缺陷。增强型蛋白质输送有可能减轻肌肉损失，但饮食蛋白质改善患者结局的能力取决于有效的蛋白质代谢。这篇综述将讨论有关成人危重患者蛋白质转运和消化、氨基酸吸收以及肌肉蛋白质合成 (MPS) 的近期文献。 最新结果：重症患者的处方蛋白质剂量与国际推荐剂量相似，但实际输送剂量仍不充分。大多数采用较高蛋白质剂量的试验均未观察到对肌肉质量、力量或功能的影响。已经观察到重症患者在胃旁路给药时，蛋白质消化和氨基酸吸收的缺陷极少，但是餐后 MPS 受损。然而，由于直接测定蛋白质处理的复杂性，文献有限。

总结：重症患者的餐后 MPS 受损，可能会加重这些患者的肌肉萎缩。在重症患者中实施的研究不仅需要评估蛋白质输送，还需要在实施增加的蛋白质剂量前进行评估。

期：4 ；页码：367-373； DOI：10.1097/MCC.0000000000000959

# Monitoring of sedation in mechanically ventilated patients using remote technology.

Author: Dusan Hanidziar, Michael Westover

Abstract: Purpose of review: Two years of coronavirus disease 2019 (COVID-19) pandemic highlighted that excessive sedation in the ICU leading to coma and other adverse outcomes remains pervasive. There is a need to improve monitoring and management of sedation in mechanically ventilated patients. Remote technologies that are based on automated analysis of electroencephalogram (EEG) could enhance standard care and alert clinicians real-time when severe EEG suppression or other abnormal brain states are detected.

Recent findings: High rates of drug-induced coma as well as delirium were found in several large cohorts of mechanically ventilated patients with COVID-19 pneumonia. In patients with acute respiratory distress syndrome, high doses of sedatives comparable to general anesthesia have been commonly administered without defined EEG endpoints. Continuous limited-channel EEG can reveal pathologic brain states such as burst suppression, that cannot be diagnosed by neurological examination alone. Recent studies documented that machine learning-based analysis of continuous EEG signal is feasible and that this approach can identify burst suppression as well as delirium with high specificity.

Summary: Preventing oversedation in the ICU remains a challenge. Continuous monitoring of EEG activity, automated EEG analysis, and generation of alerts to clinicians may reduce drug-induced coma and potentially improve patient outcomes.

# 远程技术在机械通气患者镇静监测中的应用。

审查目的：2019 年 (COVID-19) 的冠状病毒病流行的两年强调，ICU 中过度镇静导致昏迷和其他不良结局仍普遍存在。需要改善对机械通气患者镇静的监测和管理。基于脑电图 (EEG) 自动分析的远程技术可加强标准护理，并在检测到重度 EEG 抑制或其他异常大脑状态时实时提醒临床医生。最近的发现：在几个大型队列的 COVID-19 肺炎机械通气患者中，发现药物诱导的昏迷以及谵妄的发生率较高。在急性呼吸窘迫综合征患者中，通常给予与全身麻醉相当的高剂量镇静剂，但没有确定 EEG 终点。连续限制通道脑电图可显示爆发性抑制等病理脑状态，仅靠神经系统检查无法确诊。最近的研究证明，基于机器学习的连续 EEG 信号分析是可行的，该方法可以高度特异性地识别猝发抑制以及谵妄。

总结：在 ICU 中预防过度镇静仍是一项挑战。持续监测 EEG 活动、自动 EEG 分析和向临床医生发出警报可减少药物诱导的昏迷，并可能改善患者结局。

期：3 ；页码：360-366； DOI：10.1097/MCC.0000000000000940

# Monitoring during extracorporeal membrane oxygenation.

Author: Diana Castro, Idunn Morris, Ricardo Teijeiro-Paradis, Eddy Fan

Abstract: Purpose of review: Extracorporeal membrane oxygenation (ECMO) offers advanced mechanical support to patients with severe acute respiratory and/or cardiac failure. Ensuring an adequate therapeutic approach as well as prevention of ECMO-associated complications, by means of timely liberation, forms an essential part of standard ECMO care and is only achievable through continuous monitoring and evaluation. This review focus on the cardiorespiratory monitoring tools that can be used to assess and titrate adequacy of ECMO therapy; as well as methods to assess readiness to wean and/or discontinue ECMO support.

Recent findings: Surrogates of tissue perfusion and near infrared spectroscopy are not standards of care but may provide useful information in select patients. Echocardiography allows to determine cannulas position, evaluate cardiac structures, and function, and diagnose complications. Respiratory monitoring is mandatory to achieve lung protective ventilation and identify early lung recovery, surrogate measurements of respiratory effort and ECMO derived parameters are invaluable in optimally managing ECMO patients.

Summary: Novel applications of existing monitoring modalities alongside evolving technological advances enable the advanced monitoring required for safe delivery of ECMO. Liberation trials are necessary to minimize time sensitive ECMO related complications; however, these have yet to be standardized.

# 体外膜肺氧合期间的监测。

综述目的：体外膜肺氧合 (ECMO) 为重度急性呼吸和 / 或心力衰竭患者提供了先进的机械支持。通过及时解放的手段确保充分的治疗方法以及预防 ECMO 相关并发症形成标准 ECMO 治疗的重要部分，只有通过持续监测和评估才能实现。本综述重点关注可用于评估和滴定 ECMO 治疗充分性的心脏呼吸监测工具；以及评估准备脱离和 / 或中止 ECMO 支持的方法。

最新结果：组织灌注的替代物和近红外光谱法不是标准治疗，但可能在特定患者中提供有用的信息。超声心动图可确定插管的位置，评价心脏结构和功能，并诊断并发症。强制进行呼吸监测，以实现肺保护性通气并识别早期肺恢复，呼吸努力的替代测量和 ECMO 衍生参数在优化管理 ECMO 患者中非常有价值。

总结：现有监测模式的新型应用以及不断发展的技术进步，使得安全实施 ECMO 所需的先进监测成为可能。有必要开展自由化试验，以尽量减少时间敏感性 ECMO 相关并发症；然而，这些并发症尚未标准化。

期：3 ；页码：348-359； DOI：10.1097/MCC.0000000000000939

# Cardiac output monitoring - invasive and noninvasive.

Author: Virendra Arya, Waiel Al-Moustadi, Vikas Dutta

Abstract: Purpose of review: The purpose of this article is to review various contemporary cardiac output (CO) measurement technologies available and their utility in critically ill patients.

Recent findings: CO measurement devices can be invasive, minimally invasive, or noninvasive depending upon their method of CO measurement. All devices have pros and cons, with pulmonary artery catheter (PAC) being the gold standard. The invasive techniques are more accurate; however, their invasiveness can cause more complications. The noninvasive devices predict CO via mathematical modeling with several assumptions and are thus prone to errors in clinical situations. Recently, PAC has made a comeback into clinical practice especially in cardiac intensive care units (ICUs). Critical care echocardiography (CCE) is an upcoming tool that not only provides CO but also helps in differential diagnosis. Lack of proper training and nonavailability of equipment are the main hindrances to the wide adoption of CCE.

Summary: PAC thermodilution for CO measurement is still gold standard and most suitable in patients with cardiac pathology and with experienced user. CCE offers an alternative to thermodilution and is suitable for all ICUs; however, structural training is required.

# 心输出量监测 - 侵入性和非侵入性。

审查目的：本文的目的是审查各种现有的现代心输出量 (CO) 测量技术及其在重症患者中的效用。

最新结果：根据 CO 测量方法的不同，CO 测量器械可以是侵入性、微创或无创性的。所有器械都有优点和缺点，肺动脉导管 (PAC) 是金标准。侵入性技术更准确；然而，其侵入性可能导致更多并发症。无创器械通过几个假设的数学模型预测 CO，因此在临床情况下容易出现误差。最近，PAC 已重返临床实践，尤其是在心脏重症监护室 (ICU)。重症监护超声心动图 (CCE) 是一种即将使用的工具，不仅可提供 CO，还有助于鉴别诊断。缺乏适当的培训和缺乏设备是阻碍 CCE 广泛采用的主要障碍。

总结：PAC 热稀释法用于 CO 测量仍是金标准，最适合心脏病患者和经验丰富的用户。CCE 提供了热稀释法的替代方法，适用于所有 ICU；但是，需要结构培训。

期：3 ；页码：340-347； DOI：10.1097/MCC.0000000000000937

# New developments in the understanding of right ventricular function in acute care.

Author: Etienne Couture, Lars Gronlykke, Andre Denault

Abstract: Purpose of review: Right ventricular dysfunction has an important impact on the perioperative course of cardiac surgery patients. Recent advances in the detection and monitoring of perioperative right ventricular dysfunction will be reviewed here.

Recent findings: The incidence of right ventricular dysfunction in cardiac surgery has been associated with unfavorable outcomes. New evidence supports the use of a pulmonary artery catheter in cardiogenic shock. The possibility to directly measure right ventricular pressure by transducing the pacing port has expanded its use to track changes in right ventricular function and to detect right ventricular outflow tract obstruction. The potential role of myocardial deformation imaging has been raised to detect patients at risk of postoperative complications.

Summary: Perioperative right ventricular function monitoring is based on echocardiographic and extra-cardiac flow evaluation. In addition to imaging modalities, hemodynamic evaluation using various types of pulmonary artery catheters can be achieved to track changes rapidly and quantitatively in right ventricular function perioperatively. These monitoring techniques can be applied during and after surgery to increase the detection rate of right ventricular dysfunction. All this to improve the treatment of patients presenting early signs of right ventricular dysfunction before systemic organ dysfunction ensue.

# 急症护理中对右心室功能认识的新进展。

综述目的：右心室功能不全对心脏手术患者的围手术期过程有重要影响。现就围手术期右心室功能不全的检测和监测的最新进展作一综述。

近期结果：心脏手术中右心室功能不全的发生率与不良结局相关。新的证据支持在心源性休克中使用肺动脉导管。通过传感器起搏端口直接测量右心室压力的可能性已经扩大，可用于跟踪右心室功能的变化，并检测右心室流出道梗阻。已提出心肌形变成像的潜在作用，以检测术后并发症风险患者。

总结：围手术期右心室功能监测基于超声心动图和心外血流评价。除成像模式外，使用各种类型的肺动脉导管可实现血液动力学评价，以快速和定量跟踪围手术期右心室功能的变化。术中、术后可应用这些监测技术，提高右室功能不全的检出率。所有这些都是为了改善在全身器官功能障碍发生前出现右心室功能障碍早期体征患者的治疗。

期：3 ；页码：331-339； DOI：10.1097/MCC.0000000000000946

# The weaning from mechanical ventilation: a comprehensive ultrasound approach.

Author: Erminio Santangelo, Silvia Mongodi, Belaid Bouhemad, Francesco Mojoli

Abstract: Purpose of review: Due to heart, lung and diaphragm interactions during weaning from mechanical ventilation, an ultrasound integrated approach may be useful in the detection of dysfunctions potentially leading to weaning failure. In this review, we will summarize the most recent advances concerning the ultrasound applications relevant to the weaning from mechanical ventilation.

Recent findings: The role of ultrasonographic examination of heart, lung and diaphragm has been deeply investigated over the years. Most recent findings concern the ability of lung ultrasound in detecting weaning induced pulmonary edema during spontaneous breathing trial. Furthermore, in patients at high risk of cardiac impairments, global and anterolateral lung ultrasound scores have been correlated with weaning and extubation failure, whereas echocardiographic indexes were not. For diaphragmatic ultrasound evaluation, new indexes have been proposed for the evaluation of diaphragm performance during weaning, but further studies are needed to validate these results.

Summary: The present review summarizes the potential role of ultrasonography in the weaning process. A multimodal integrated approach allows the clinician to comprehend the pathophysiological processes of weaning failure.

# 机械通气的撤机：一种综合超声方法。

综述目的：由于机械通气撤机期间的心脏、肺和膈肌相互作用，超声集成方法可能有助于检测可能导致撤机失败的功能障碍。在本综述中，我们将总结与机械通气撤机相关的超声应用的最新进展。

近期发现：多年来对心、肺、膈的超声检查作用进行了深入的研究。最近的研究结果涉及在自主呼吸试验期间肺部超声检测撤机诱发肺水肿的能力。此外，在存在高危心脏损伤的患者中，全肺和前外侧肺超声评分与撤机和拔管失败相关，而超声心动图指标与撤机和拔管失败不相关。对于膈肌超声评估，已经提出了评价断奶时膈肌性能的新指标，但这些结果还需要进一步的研究来验证。

总结：本综述总结了超声检查在断奶过程中的潜在作用。多模式综合方法允许临床医生理解撤机失败的病理生理过程。

期：3 ；页码：322-330； DOI：10.1097/MCC.0000000000000941

# Artificial intelligence and clinical deterioration.

Author: James Malycha, Stephen Bacchi, Oliver Redfern

Abstract: Purpose of review: To provide an overview of the systems being used to identify and predict clinical deterioration in hospitalised patients, with focus on the current and future role of artificial intelligence (AI).

Recent findings: There are five leading AI driven systems in this field: the Advanced Alert Monitor (AAM), the electronic Cardiac Arrest Risk Triage (eCART) score, Hospital wide Alert Via Electronic Noticeboard, the Mayo Clinic Early Warning Score, and the Rothman Index (RI). Each uses Electronic Patient Record (EPR) data and machine learning to predict adverse events. Less mature but relevant evolutions are occurring in the fields of Natural Language Processing, Time and Motion Studies, AI Sepsis and COVID-19 algorithms.

Summary: Research-based AI-driven systems to predict clinical deterioration are increasingly being developed, but few are being implemented into clinical workflows. Escobar et al. (AAM) provide the current gold standard for robust model development and implementation methodology. Multiple technologies show promise, however, the pathway to meaningfully affect patient outcomes remains challenging.

# 人工智能和临床恶化。

审查目的：提供用于识别和预测住院患者临床恶化的系统概述，重点关注人工智能 (AI) 当前和未来的作用。

最新结果：该领域有 5 个领先的 AI 驱动系统：高级警报监视器 (AAM)、电子心脏骤停风险分类 (eCART) 评分、通过电子通知板的医院警报范围、梅奥诊所早期警告评分和 Rothman 指数 (RI)。每种方法均使用电子患者记录 (EPR) 数据和机器学习来预测不良事件。在自然语言处理、时间和运动研究、AI Sepsis 和 COVID-19 算法领域出现了不太成熟但相关的演变。

总结：用于预测临床恶化的基于研究的 AI 驱动系统正在逐渐开发，但很少被应用于临床工作流程。Escobar 等人 (AAM) 为稳健的模型开发和实现方法提供了当前的金标准。多种技术显示出了希望，然而，对患者结局产生有意义的影响的途径仍具有挑战性。

期：3 ；页码：315-321； DOI：10.1097/MCC.0000000000000945

# Remote monitoring in the use of extracorporeal membrane oxygenation and acute mechanical circulatory support.

Author: Aaron Aguirre, Kenneth Shelton

Abstract: Purpose of review: To provide an overview of the role of remote monitoring tools in management of critically-ill patients requiring acute mechanical circulatory support (MCS).

Recent findings: Tele-critical care systems have received new interest during the COVID-19 pandemic, which has stretched the capacity of health systems everywhere. At the same time, utilization of MCS and extracorporeal membrane oxygenation (ECMO) technologies has increased during the pandemic. The opportunity for remote monitoring and clinical decision support for ECMO and acute MCS devices has been recognized by industry partners, with several major platforms implementing technology infrastructure for it in available products. Healthcare systems face challenges interfacing multiple devices from multiple manufacturers with each other and with their designated electronic health records. Furthermore, the availability of data must be combined with algorithms for alerting on clinical events and with implementation systems to act upon these alerts. Studies are not yet published validating remote monitoring platforms for ECMO and MCS in clinical care.

Summary: Remote monitoring for MCS devices represents a major opportunity for further investigation to improve the utilization of these devices and better serve patients.

# 使用体外膜肺氧合和急性机械循环支持的远程监测。

审查目的：概述远程监测工具在需要急性机械循环支持 (MCS) 的重症患者管理中的作用。

最近的发现：在 COVID-19 大流行期间，远程重症监护系统获得了新的兴趣，这种流行扩大了各地卫生系统的能力。同时，在大流行期间，MCS 和体外膜肺氧合 (ECMO) 技术的使用率增加。行业合作伙伴已认识到，ECMO 和急性 MCS 设备有机会进行远程监测和临床决策支持，几个主要平台在可用产品中实施其技术基础设施。卫生保健系统面临着将来自多个制造商的多个设备彼此连接，并与指定的电子健康记录连接的挑战。此外，数据的可用性必须与临床事件警报算法和实施系统相结合，以应对这些警报。尚未发表验证临床护理中 ECMO 和 MCS 远程监测平台的研究。

总结：MCS 器械的远程监测代表了进一步研究以改善这些器械的使用并更好地服务于患者的重大机会。

期：3 ；页码：308-314； DOI：10.1097/MCC.0000000000000949

# Lung aeration, ventilation, and perfusion imaging.

Author: Lorenzo Ball, Gaetano Scaramuzzo, Jacob Herrmann, Maurizio Cereda

Abstract: Purpose of review: Lung imaging is a cornerstone of the management of patients admitted to the intensive care unit (ICU), providing anatomical and functional information on the respiratory system function. The aim of this review is to provide an overview of mechanisms and applications of conventional and emerging lung imaging techniques in critically ill patients.

Recent findings: Chest radiographs provide information on lung structure and have several limitations in the ICU setting; however, scoring systems can be used to stratify patient severity and predict clinical outcomes. Computed tomography (CT) is the gold standard for assessment of lung aeration but requires moving the patients to the CT facility. Dual-energy CT has been recently applied to simultaneous study of lung aeration and perfusion in patients with respiratory failure. Lung ultrasound has an established role in the routine bedside assessment of ICU patients, but has poor spatial resolution and largely relies on the analysis of artifacts. Electrical impedance tomography is an emerging technique capable of depicting ventilation and perfusion at the bedside and at the regional level.

Summary: Clinicians should be confident with the technical aspects, indications, and limitations of each lung imaging technique to improve patient care.

# 肺通气、通气和灌注成像。

审查目的：肺成像是重症监护室 (ICU) 患者管理的基石，提供呼吸系统功能的解剖学和功能性信息。本综述的目的是概述常规和新兴肺成像技术在重症患者中的机制和应用。

近期发现：胸部 x 线片提供了肺结构的信息，在 ICU 环境中有一些局限性；但是，评分系统可用于对患者严重程度进行分层并预测临床结局。计算机断层扫描 (CT) 是评估肺通气的金标准，但需要将患者转移到 CT 机构。双能量 CT 最近被应用于同时研究呼吸衰竭患者的肺通气和灌注。肺部超声在 ICU 患者常规床边评估中的作用已确立，但空间分辨率较差，在很大程度上依赖于伪影的分析。电阻抗断层成像是一种新出现的技术，能够在床边和区域水平描述通气和灌注。

总结：临床医生应该对每种肺成像技术的技术方面、适应症和局限性有信心，以改善患者治疗。

期：3 ；页码：302-307； DOI：10.1097/MCC.0000000000000942

# Electrical impedance tomography in the adult intensive care unit: clinical applications and future directions.

Author: Jonah Rubin, Lorenzo Berra

Abstract: Purpose of review: Electrical impedance tomography (EIT) is a novel, noninvasive, radiation-free, bedside imaging and monitoring tool to assess and visualize regional distribution of lung ventilation and perfusion. Although primarily a research tool, rapidly emerging data are beginning to define its clinical role, and it is poised to become a ubiquitous addition to the arsenal of the intensive care unit (ICU). In this review, we summarize the data supporting clinical use of EIT in adult ICUs, with an emphasis on appropriate application while highlighting future directions.

Recent findings: Recent major studies have primarily focused on the role of EIT in setting correct positive end-expiratory pressure to balance regional overdistention and collapse. Over the last few years, our Lung Rescue Team has demonstrated that incorporating EIT into a multimodal approach to individualizing ventilator management can improve outcomes, particularly in the obese. We also review recent data surrounding EIT use during COVID, as well as other broad potential applications.

Summary: As EIT becomes more common and its clinical role more defined, intensivists will benefit from a clear understanding of its applications and limitations.

# 成人重症监护室中的电阻抗断层扫描：临床应用和未来方向。

综述目的：电阻抗断层成像 (EIT) 是一种新型的无创性无辐射的床旁成像和监测工具，用于评估和显示肺通气和灌注的区域分布。虽然主要是一种研究工具，但迅速出现的数据开始定义其临床作用，并且它有望成为重症监护室 (ICU) 武库中的一个无处不在的补充。在本综述中，我们总结了支持成人 ICU 中 EIT 临床使用的数据，强调了适当的应用，同时强调了未来的方向。

近期结果：近期主要研究主要集中于 EIT 在设置正确的呼气末正压以平衡局部过度扩张和衰竭中的作用。在过去的几年中，我们的肺抢救团队已经证明，将 EIT 结合到个体化呼吸机管理的多模式方法中可以改善结局，尤其是在肥胖患者中。我们还回顾了有关 COVID 期间使用 EIT 的最新数据以及其他广泛的潜在应用。

总结：随着 EIT 越来越普遍，其临床作用也越来越明确，重症监护医生将从对其应用和局限性的明确理解中获益。

期：3 ；页码：292-301； DOI：10.1097/MCC.0000000000000936

# Editorial: Monitoring patients in the ICU in 2022.

Author: Jeanine Wiener-Kronish

# 社论：2022 年 ICU 患者监测。

期：3 ；页码：290-291； DOI：10.1097/MCC.0000000000000938

# Resuscitation guideline highlights.

Author: Theresa Olasveengen, Giuseppe Ristagno, Michael Smyth

Abstract: Purpose of review: The purpose of this review was to give an overview of the most significant updates in resuscitation guidelines and provide some insights into the new topics being considered in upcoming reviews.

Recent findings: Recent updates to resuscitation guidelines have highlighted the importance of the earlier links in the chain-of-survival aimed to improve early recognition, early cardiopulmonary resuscitation (CPR) and defibrillation. Empowering lay rescuers with the support of emergency medical dispatchers or telecommunicators and engaging the community through dispatching volunteers and Automated External Defibrillators, are considered key in improving cardiac arrest outcomes. Novel CPR strategies such as passive insufflation and head-up CPR are being explored, but lack high-certainty evidence. Increased focus on survivorship also highlights the need for more evidence based guidance on how to facilitate the necessary follow-up and rehabilitation after cardiac arrest. Many of the systematic and scoping reviews performed within cardiac arrest resuscitation domains identifies significant knowledge gaps on key elements of our resuscitation practices. There is an urgent need to address these gaps to further improve survival from cardiac arrest in all settings.

Summary: A continuous evidence evaluation process for resuscitation after cardiac arrest is triggered by new evidence or request by the resuscitation community, and provides more current and relevant guidance for clinicians.

# 复苏指南要点。

审查目的：本审查的目的是概述复苏指南中最重要的更新，并对即将进行的审查中考虑的新主题提供一些见解。

最新结果：复苏指南的近期更新强调了旨在改善早期识别、早期心肺复苏 (CPR) 和除颤的早期生存链联系的重要性。在紧急医疗派遣者或官员的支持下赋予外行人权力，并通过派遣志愿者和自动体外除颤器吸引公众，被认为是改善心脏骤停结局的关键。目前正在探索新型 CPR 策略，如被动注气和头高位 CPR，但缺乏高度确定性证据。对生存率的关注增加也强调需要更多基于证据的指导，以帮助心脏骤停后进行必要的随访和康复。在心脏骤停复苏领域进行的许多系统和范围审查发现，我们复苏实践的关键要素存在显著的知识缺口。目前迫切需要解决这些差距，以进一步改善所有情况下心脏骤停的生存率。

小结：复苏界的新证据或要求触发了心脏骤停后复苏的连续证据评估过程，为临床医生提供了更多最新和相关的指南。

期：3 ；页码：284-289； DOI：10.1097/MCC.0000000000000933

# Extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest - who, when, and where?.

Author: Adam Gottula, Robert Neumar, Cindy Hsu

Abstract: Purpose of review: Extracorporeal cardiopulmonary resuscitation (ECPR) is an invasive and resource-intensive therapy used to care for patients with refractory cardiac arrest. In this review, we highlight considerations for the establishment of an ECPR system of care for patients suffering refractory out-of-hospital cardiac arrest (OHCA).

Recent findings: ECPR has been shown to improve neurologically favorable outcomes in patients with refractory cardiac arrest in numerous studies, including a single randomized control trial. Successful ECPR programs are typically part of a comprehensive system of care that optimizes all phases of OHCA management. Given the resource-intensive and time-sensitive nature of ECPR, patient selection criteria, timing of ECPR, and location must be well defined. Many knowledge gaps remain within ECPR systems of care, postcardiac arrest management, and neuroprognostication strategies for ECPR patients.

Summary: To be consistently successful, ECPR must be a part of a comprehensive OHCA system of care that optimizes all phases of cardiac arrest management. Future investigation is needed for the knowledge gaps that remain.

# 院外心脏骤停的体外心肺复苏 - 何人、何时、何处？

综述目的：体外心肺复苏 (ECPR) 是一种侵入性的资源密集型疗法，用于治疗难治性心脏骤停患者。在本综述中，我们强调了为难治性院外心脏骤停 (OHCA) 患者建立 ECPR 护理系统的注意事项。

最近的发现：在许多研究中，包括一项随机对照试验，已经证明 ECPR 可改善难治性心脏骤停患者的神经系统有利结局。成功的 ECPR 项目通常是优化 OHCA 管理所有阶段的综合护理系统的一部分。鉴于 ECPR 的资源密集性和时间敏感性，必须明确患者选择标准、ECPR 时机和部位。许多知识差距仍然存在于 ECPR 系统的护理、心跳骤停后管理和 ECPR 患者的神经预后策略中。

总结：为了始终成功，ECPR 必须是优化心脏骤停管理所有阶段的全面 OHCA 护理系统的一部分。需要对仍存在的知识差距进行进一步研究。

期：3 ；页码：276-283； DOI：10.1097/MCC.0000000000000944

# The future of resuscitation education.

Author: Janet Bray, Robert Greif, Peter Morley

Abstract: Purpose of review: The purpose of this review is to provide an update for critical care clinicians and providers on the recent developments in patient and healthcare professional (HCP) resuscitation education.

Recent findings: The family members of patients at high-risk of cardiac arrest need to be provided with access to basic life support (BLS) training. Many low-cost methods are now available to provide BLS training beyond attending a traditional BLS instructor-led cardiopulmonary resuscitation (CPR) class. Hybrid-blended learning formats provide new opportunities to receive individualized CPR-training in a flexible and convenient format. HCPs' participation in accredited advanced life support courses improves patient outcomes. Monitoring HCPs exposure to resuscitation and supplementing with frequent simulation is recommended. Training should include human factors and nontechnical skills. Volunteering for first responder programs when off-duty provides a great opportunity for HCP's to improve out-of-hospital cardiac arrest survival and increase exposure to resuscitation.

Summary: Frequent resuscitation education and training is critical to improving cardiac arrest patient outcomes. Recent evidence shows the effectiveness of technological developments to improve access to training and outcomes.

# 复苏教育的未来。

审查目的：本审查的目的是为重症监护临床医生和医务人员提供患者和医疗保健专业人员 (HCP) 复苏教育最新进展的更新。

最新研究结果：心脏骤停高危患者的家属需要获得基本生命支持 (BLS) 培训。除了参加传统的 BLS 讲师指导的心肺复苏 (CPR) 课程外，现在还有许多低成本的方法可以提供 BLS 培训。混合混合学习格式提供了以灵活方便的形式接受个体化 CPR 培训的新机遇。HCP 参加认证的高级生命支持课程可改善患者结局。建议监测 HCP 的复苏暴露，并补充频繁模拟。培训应包括人为因素和非技术技能。下班后志愿参加第一个应答者项目为 HCP 提供了改善院外心脏骤停生存率和增加复苏暴露的大好机会。

总结：频繁的复苏教育和培训对改善心脏骤停患者的结局至关重要。最近的证据表明，技术开发的有效性可改善获得培训和结果的机会。

期：3 ；页码：270-275； DOI：10.1097/MCC.0000000000000932

# Cardiac arrest centres: what, who, when, and where?.

Author: Andrew Ho, Jun Yeo, Marcus Ong

Abstract: Purpose of review: Cardiac arrest centres (CACs) may play a key role in providing postresuscitation care, thereby improving outcomes in out-of-hospital cardiac arrest (OHCA). There is no consensus on CAC definitions or the optimal CAC transport strategy despite advances in research. This review provides an updated overview of CACs, highlighting evidence gaps and future research directions.

Recent findings: CAC definitions vary worldwide but often feature 24/7 percutaneous coronary intervention capability, targeted temperature management, neuroprognostication, intensive care, education, and research within a centralized, high-volume hospital. Significant evidence exists for benefits of CACs related to regionalization. A recent meta-analysis demonstrated clearly improved survival with favourable neurological outcome and survival among patients transported to CACs with conclusions robust to sensitivity analyses. However, scarce data exists regarding 'who', 'when', and 'where' for CAC transport strategies. Evidence for OHCA patients without ST elevation postresuscitation to be transported to CACs remains unclear. Preliminary evidence demonstrated greater benefit from CACs among patients with shockable rhythms. Randomized controlled trials should evaluate specific strategies, such as bypassing nearest hospitals and interhospital transfer.

Summary: Real-world study designs evaluating CAC transport strategies are needed. OHCA patients with underlying culprit lesions, such as those with ST-elevation myocardial infarction (STEMI) or initial shockable rhythms, will likely benefit the most from CACs.

# 心脏骤停中心：什么、何人、何时、何地？

审查目的：心脏骤停中心 (CAC) 可能在提供复苏后护理方面发挥关键作用，从而改善院外心脏骤停 (OHCA) 的结局。尽管研究取得了进展，但在 CAC 定义或最佳 CAC 转运策略方面尚未达成共识。本综述提供了 CACs 的更新概述，突出了证据差距和未来的研究方向。

近期结果：CAC 的定义在全球各不相同，但通常以 24/7 的经皮冠状动脉介入治疗能力、目标温度管理、神经预后、重症监护、教育以及集中的大型医院内的研究为特征。存在与区域化相关的 crc 获益的显著证据。最近的一项荟萃分析表明，转运至 CACs 的患者的生存期明显改善，神经系统结局良好，生存期良好，结论对敏感性分析是稳健的。然而，关于 CAC 运输策略的 “谁”、“何时” 和 “在哪里” 的数据很少。复苏后无 ST 段抬高的 OHCA 患者被转运至 CACs 的证据尚不清楚。初步证据表明，在可电击节律的患者中，CACs 的获益更大。随机对照试验应该评估特定的策略，例如绕过最近的医院和院内转运。

总结：需要评估 CAC 转运策略的现实世界研究设计。具有潜在致病病变的 OHCA 患者，例如 ST 段抬高型心肌梗死 (STEMI) 或初始可电击节律的患者，将可能从 CACs 中获益最大。

期：3 ；页码：262-269； DOI：10.1097/MCC.0000000000000934

# undefined - 心脏骤停中心：什么、何人、何时、何地？.md

Surviving cardiac arrest - what do we know about recovery & survivorship?.

Author: Kelly Sawyer

Abstract: Purpose of review: There has been increasing interest in examining how cardiac arrest survivors and their families experience life after sudden cardiac arrest (SCA). Understanding their experiences provides a basis to study tools and interventions to improve short- and long-term recovery and rehabilitation.

Recent findings: Qualitative interview and survey-style studies explored the lived experience of SCA survivors and revealed common themes (e.g., need for recovery expectations and long-term follow-up resources). A heightened awareness for the unique needs of family and loved ones of survivors led to qualitative studies focusing on these members as well. Methodology papers published portend prospective assessment and follow-up cohort studies. However, no investigations evaluating discharge processes or specific interventions directed at domain impairments common after SCA were identified in the review period. International work continues to identify patient and family-centered priorities for outcome measurement and research.

Summary: In line with increased recognition of the importance for recovery and rehabilitation after SCA, there has been a commensurate increase in investigations documenting the needs of survivors and families surviving SCA. Pediatric and underserved populations continue to be understudied with regards to recovery after SCA.

# 心脏骤停存活？我们对恢复和存活情况有何了解？

综述目的：人们越来越关注检查心脏骤停幸存者及其家人在心脏骤停 (SCA) 后如何体验生活。了解他们的经验为研究工具和干预措施提供了基础，以改善短期和长期恢复和康复。

最新结果：定性访谈和调查式研究探索了 SCA 幸存者的生活经验，并揭示了共同主题（例如，恢复预期的需求和长期随访资源）。提高对幸存者家属和亲人独特需求的认识，导致对这些成员也进行定性研究。发表的方法学论文描述了前瞻性评估和随访队列研究。但是，在审查期间，未发现评估放电过程或针对 SCA 后常见的域损伤进行特定干预的研究。国际工作继续确定以患者和家庭为中心的结局测量和研究的优先顺序。

总结：随着对 SCA 后康复和康复重要性的认识增加，记录 SCA 存活者和家庭需求的调查也相应增加。SCA 后恢复方面，儿童和服务不足人群的研究仍然不足。

期：3 ；页码：256-261； DOI：10.1097/MCC.0000000000000935

# How technology can save lives in cardiac arrest.

Author: Tommaso Scquizzato, Lorenzo Gamberini, Federico Semeraro

Abstract: Purpose of review: Technology is being increasingly implemented in the fields of cardiac arrest and cardiopulmonary resuscitation. In this review, we describe how recent technological advances have been implemented in the chain of survival and their impact on outcomes after cardiac arrest. Breakthrough technologies that are likely to make an impact in the future are also presented.

Recent findings: Technology is present in every link of the chain of survival, from prediction, prevention, and rapid recognition of cardiac arrest to early cardiopulmonary resuscitation and defibrillation. Mobile phone systems to notify citizen first responders of nearby out-of-hospital cardiac arrest have been implemented in numerous countries with improvement in bystanders' interventions and outcomes. Drones delivering automated external defibrillators and artificial intelligence to support the dispatcher in recognising cardiac arrest are already being used in real-life out-of-hospital cardiac arrest. Wearables, smart speakers, surveillance cameras, and artificial intelligence technologies are being developed and studied to prevent and recognize out-of-hospital and in-hospital cardiac arrest.

Summary: This review highlights the importance of technology applied to every single step of the chain of survival to improve outcomes in cardiac arrest. Further research is needed to understand the best role of different technologies in the chain of survival and how these may ultimately improve outcomes.

# 技术如何挽救心脏骤停患者的生命。

审查目的：技术在心脏骤停和心肺复苏领域的应用日益增多。在本综述中，我们描述了如何在生存链中实施最新的技术进步及其对心脏骤停后结局的影响。此外，还介绍了可能在未来产生影响的突破性技术。最新发现：技术存在于生存链的每个环节，从预测、预防、快速识别心脏骤停到早期心肺复苏和除颤。许多国家已经实施了手机系统，用于通知附近院外心脏骤停的首个缓解者，旁观者干预和结局改善。为支持调度员识别心脏骤停而提供自动体外除颤器和人工智能支持的无人飞机已经在现实生活中用于院外心脏骤停。正在开发和研究可穿戴设备、智能扬声器、监控摄像机和人工智能技术，以预防和识别院外和院内心脏骤停。

总结：本综述强调了应用于生存链每一步骤的技术对改善心脏骤停结局的重要性。需要进一步的研究来了解不同技术在生存链中的最佳作用，以及这些技术如何最终改善结局。

期：3 ；页码：250-255； DOI：10.1097/MCC.0000000000000930

# Temperature control after cardiac arrest: friend or foe.

Author: Jerry Nolan, Jasmeet Soar

Abstract: Purpose of review: Most patients who are successfully resuscitated after cardiac arrest are initially comatose and require mechanical ventilation and other organ support in an ICU. Best practice has been to cool these patients and control their temperature at a constant value in the range of 32-36 oC for at least 24 h. But the certainty of the evidence for this practice is increasingly being challenged. This review will summarize the evidence on key aspects of temperature control in comatose postcardiac arrest patients.

Recent findings: The Targeted Temperature Management 2 (TTM-2) trial documented no difference in 6-month mortality among comatose postcardiac arrest patients managed at 33 oC vs. targeted normothermia. A systematic review and meta-analysis completed by the Advanced Life Support (ALS) Task Force of the International Liaison Committee on Resuscitation (ILCOR) concluded that temperature control with a target of 32-34 [degrees]C did not improve survival or favourable functional outcome after cardiac arrest. Two observational studies have documented an association between predicted moderate hypoxic-ischaemic brain injury and better outcome with temperature control at 33-34 oC compared with 35-36 oC.

Summary: We suggest actively preventing fever by targeting a temperature 37.5 oC or less for those patients who remain comatose following return of spontaneous circulation (ROSC) after cardiac arrest.

# 心脏骤停后的温度控制：朋友或朋友。

回顾目的：大多数在心脏骤停后成功复苏的患者最初是昏迷的，在 ICU 需要机械通气和其他器官支持。最佳实践是使这些患者降温，并将其温度控制在 32-36 ℃的恒定值范围内至少 24h。但这种实践证据的确定性越来越受到挑战。本综述将总结关于心脏骤停后昏迷患者中温度控制关键方面的证据。

最近的研究结果：靶向温度管理 2 (TTM-2) 试验证明，采用 33 ℃与目标体温正常管理的心脏骤停后昏迷患者 6 个月死亡率无差异。复苏国际联络委员会 (ILCOR) 高级生命支持 (ALS) 工作组完成的一项系统性审查和荟萃分析得出结论，在心脏骤停后，以 32-34 [℃] 的目标进行温度控制不会改善生存率或有利的功能结局。两项观察性研究已证实，与 35-36 oC 剂量相比，在 33-34 oC 剂量下，预测的中度缺氧缺血性脑损伤与更好的温度控制结局之间存在关联。

总结：我们建议，对于心脏骤停后自主循环恢复 (ROSC) 后仍昏迷的患者，应将目标温度设定为 37.5 oC 或更低，以积极预防发热。

期：3 ；页码：244-249； DOI：10.1097/MCC.0000000000000943

# Cardiac arrest and coronavirus disease 2019.

Author: Enrico Baldi, Andrea Cortegiani, Simone Savastano

Abstract: Purpose of review: The impact of the coronavirus disease 2019 (COVID-19) on the cardiovascular system has been highlighted since the very first weeks after the severe acute respiratory syndrome coronavirus 2 identification. We reviewed the influence of COVID-19 pandemic on cardiac arrest, both considering those occurred out of the hospital (OHCA) and in the hospital (IHCA).

Recent findings: An increase in OHCA incidence occurred in different countries, especially in those regions most burdened by the COVID-19, as this seems to be bounded to the pandemic trend. A change of OHCA patients' characteristics, with an increase of the OHCA occurred at home, a decrease in bystander cardiopulmonary resuscitation and automated external defibrillator use before Emergency Medical Service (EMS) arrival and an increase in non-shockable rhythms, have been highlighted. A dramatic drop in the OHCA patients' survival was pointed out in almost all the countries, regardless of the high or low-incidence of COVID-19 cases. Concerning IHCA, a reduction in survival was highlighted in patients with COVID-19 who sustained a cardiac arrest.

Summary: Cardiac arrest occurrence and survival were deeply affected by the pandemic. Informative campaigns to the population to call EMS in case of need and the re-allocation of the prehospital resources basing on the pandemic trend are needed to improve survival.

# 2019 年心脏骤停和冠状病毒病。

审查目的：自发现严重急性呼吸综合征冠状病毒 2 型后最初几周，就已强调了 2019 年冠状病毒病 (COVID-19) 对心血管系统的影响。我们回顾了 COVID-19 大流行对心脏骤停的影响，考虑了发生在医院外 (OHCA) 和医院内 (IHCA) 的心脏骤停。

最近的发现：OHCA 发病率的增加发生在不同的国家，尤其是那些受 COVID-19 负担最大的地区，因为这似乎与大流行趋势有关。强调了 OHCA 患者特征的变化，即在家中发生的 OHCA 增加、在紧急医疗服务 (EMS) 到达之前旁观者心肺复苏术和自动体外除颤器的使用减少以及非电击节律的增加。几乎所有国家都指出 OHCA 患者的生存率急剧下降，无论 COVID-19 病例的发病率高还是低。关于 IHCA，COVID-19 持续心脏骤停患者的生存率下降。

总结：心脏骤停的发生和存活受到大流行的严重影响。为了提高生存率，需要对人群进行信息性讨论，以便在需要时呼叫 EMS，并根据大流行趋势重新分配院前资源。

期：3 ；页码：237-243； DOI：10.1097/MCC.0000000000000931

# Health inequities in out-of-hospital cardiac arrest.

Author: Adam Boulton, Marina Del Rios, Gavin Perkins

Abstract: Purpose of review: Out-of-hospital cardiac arrest (OHCA) is a time-critical emergency in which a rapid response following the chain of survival is crucial to save life. Disparities in care can occur at each link in this pathway and hence produce health inequities. This review summarises the health inequities that exist for OHCA patients and suggests how they may be addressed.

Recent findings: There is international evidence that the incidence of OHCA is increased with increasing deprivation and in ethnic minorities. These groups have lower rates of bystander CPR and bystander-initiated defibrillation, which may be due to barriers in accessing cardiopulmonary resuscitation training, provision of public access defibrillators, and language barriers with emergency call handlers. There are also disparities in the ambulance response and in-hospital care following resuscitation. These disadvantaged communities have poorer survival following OHCA.

Summary: OHCA disproportionately affects deprived communities and ethnic minorities. These groups experience disparities in care throughout the chain of survival and this appears to translate into poorer outcomes. Addressing these inequities will require coordinated action that engages with disadvantaged communities.

# 院外心脏骤停的健康影响。

审查目的：院外心脏骤停 (OHCA) 是一种时间关键急症，在这种情况下，遵循生存链的快速反应对挽救生命至关重要。护理方面的差异可能发生在这一途径的每个环节，因此产生健康收益。本综述总结了 OHCA 患者存在的健康问题，并提出了如何解决这些问题。

最近的发现：国际证据表明，OHCA 的发病率随着剥夺的增加和在少数民族中增加。这些群体的旁观者 CPR 和旁观者启动的除颤率较低，这可能是由于在获取心肺复苏培训、提供公共通路除颤器方面存在障碍，以及紧急呼叫处理者存在语言障碍。复苏后的救护车响应和院内护理也存在差异。这些贫困社区在 OHCA 后的生存情况较差。

总结：OHCA 不成比例地影响贫困社区和少数民族。这些患者组在整个生存链中的护理存在差异，这似乎转化为较差的结局。解决这些不利现象将需要与贫困社区采取协调行动。

期：3 ；页码：229-236； DOI：10.1097/MCC.0000000000000947

# Perioperative screening and management in elective complex hepatobiliary surgery.

Author: Akila Rajakumar, Ashwin Rammohan, Mohamed Rela

Abstract: Purpose of review: Preoperative optimization and structured evidence-based perioperative care of a patient undergoing complex hepatobiliary (HPB) surgery are essential components in their management. Apart from advances in surgical technique, these perioperative measures have resulted in substantial reductions in morbidity and mortality. There hence, remains a continued need to have evidence-based updation in their management algorithm to ensure optimal outcomes.

Recent findings: We present an evidence-based overview of the preoperative screening, optimization and perioperative management of patients undergoing complex HPB surgery.

Summary: Perioperative care of these fragile patients is an evidence-based dynamic process. Optimal patient management undergoing HPB surgery requires risk assessment and stratification, and meticulous attention to the correction of underlying conditions. Despite this, postoperative morbidity remains relatively high and requires a cohesive multidisciplinary approach to minimize complications.

# 择期复杂肝胆外科手术的围手术期筛查和管理。

综述目的：对接受复杂肝胆 (HPB) 手术的患者进行术前优化和结构化循证围手术期护理是管理的重要组成部分。除了手术技术的进步外，这些围手术期措施也显著降低了发病率和死亡率。因此，仍然需要对其管理方法进行循证更新，以确保获得最佳结局。

近期发现：我们对复杂 HPB 手术患者的术前筛查、优化和围手术期管理进行了循证综述。

总结：对这些脆弱患者的围手术期护理是一个循证的动态过程。进行 HPB 手术的最佳患者管理需要进行风险评估和分层，并密切关注基础疾病的纠正。尽管如此，术后发病率仍然相对较高，需要联合多学科方法将并发症降至最低。

期：2 ；页码：221-228； DOI：10.1097/MCC.0000000000000922

# The liver-gut-axis: initiator and responder to sepsis.

Author: Michael Bauer

Abstract: Purpose of review: The 'gut-liver axis' is thought to play an important role in pathogenesis of sepsis. Despite a wealth of experimental data to support the concept of reciprocal crosstalk between gut and liver through bacterial translocation and shaping of the microbiome by liver-derived molecules, for example bile acids, clinical data, and in particular diagnostic and therapeutic options, are limited.

Recent findings: Assessment of organ failure in the current definition of sepsis is operationalized by means of the Sequential Organ Failure Assessment (SOFA) score, including exclusively bilirubin to reflect the complex functions of the liver but ignoring the gut. However, our understanding of the intestinal microbiome and how it is affected by critical illness has clearly improved. Microbiota maintain gut-barrier function and modulate the innate and adaptive immune system. The best-defined intervention affecting the gut microbiome, that is selective decontamination of the digestive tract (SDD) is clinically studied regarding prevention of nosocomial lung infection and antibiotic resistance patterns, although its impact on liver function has not been systematically evaluated in critical illness.

Summary: Characterization of liver function beyond bilirubin and the microbiome can be achieved with contemporary sequencing and metabolomic techniques. Such studies are essential to understand how gut-liver crosstalk and 'dysbiosis' affect susceptibility to and outcome of sepsis.

# 肝 - 肠轴：脓毒血症的启动者和应答者。

综述目的：“肠 - 肝轴” 被认为在败血症发病机制中发挥重要作用。尽管有大量实验数据支持通过细菌易位和肝源性分子对微生物组进行定形来实现肠道和肝脏之间的相互串扰的概念，例如胆汁酸、临床数据，尤其是诊断和治疗选择，但这些数据有限。

最近的发现：在目前的脓毒症定义中，器官衰竭的评估是通过序贯器官衰竭评估 (SOFA) 评分来操作的，包括胆红素仅反映肝脏的复杂功能，而忽略了肠道。然而，我们对肠道微生物组及其如何受危重症影响的了解有了明显改善。微管蛋白维持肠道屏障功能，调节先天和适应性免疫系统。在预防院内肺部感染和抗生素耐药模式方面，对影响肠道微生物组（选择性消化道净化 (SDD)）的最佳定义干预措施进行了临床研究，尽管尚未在危重症中系统地评价其对肝功能的影响。

总结：使用现代测序和代谢组学技术，可以表征除胆红素和微生物组之外的肝功能。此类研究对于了解肠 - 肝串音和 “微生性” 如何影响败血症的易感性和结局至关重要。

期：2 ；页码：216-220； DOI：10.1097/MCC.0000000000000921

# Immunosuppressive drugs and associated complications in abdominal organ transplantation.

Author: Jody Olson

Abstract: Purpose of review: Intensive care management of patients who have undergone organ transplantation of liver, small bowel, pancreas, and/or kidney requires a basic knowledge of immunosuppression principles and the management of immunosuppressive medications. This review highlights the core principles of immunosuppression management in abdominal organ transplantation with a focus on complications arising from immunosuppressive drugs, both in the immediate postoperative period and in long-term usage.

Recent findings: The general principles of management of immunosuppression in the abdominal organ transplant population have remained largely unchanged. Improvements in drug monitoring coupled with improvements in knowledge of pathways involved in allograft rejection have further refined immunosuppressive therapy. Infectious and central nervous system complications remain prevalent and are common complications of immunosuppressive drug therapy.

Summary: For the intensive care professional who cares for abdominal organ transplant recipients, a foundational knowledge of the core principles of immunosuppression management is essential. In addition, an understanding of the common immunosuppressive drug regimens and the complications associated with these regimens is required for optimal management, risk assessment, and outcomes.

# 腹部器官移植中的免疫抑制药物和相关并发症。

审查目的：对肝脏、小肠、胰腺和 / 或肾脏器官移植患者的重症监护管理要求了解免疫抑制原则和免疫抑制药物管理的基本知识。本综述强调了腹部器官移植免疫抑制管理的核心原则，重点关注术后即刻和长期使用免疫抑制药物产生的并发症。

近期结果：腹部器官移植人群免疫抑制管理的一般原则基本保持不变。药物监测的改善以及对参与同种异体排斥反应的通路的了解的改善进一步改善了免疫抑制治疗。感染和中枢神经系统并发症仍很普遍，是免疫抑制药物治疗的常见并发症。

小结：对于护理腹部器官移植受者的重症监护专业人员，免疫抑制管理核心原则的基础知识至关重要。此外，为了优化管理、风险评估和结局，需要了解常见的免疫抑制药物方案以及与这些方案相关的并发症。

期：2 ；页码：208-215； DOI：10.1097/MCC.0000000000000927

# Acute liver failure.

Author: Francesco Vasques, Anna Cavazza, William Bernal

Abstract: Purpose of review: Present an outline of acute liver failure, from its definition to its management in critical care, updated with findings of selected newer research.

Recent findings: Survival of patients with acute liver failure has progressively improved. Intracranial hypertension complicating hepatic encephalopathy is now much less frequent than in the past and invasive ICP monitoring is now rarely used. Early renal replacement therapy and possibly therapeutic plasma exchange have consolidated their role in the treatment. Further evidence confirms the low incidence of bleeding in these patients despite striking abnormalities in standard tests of coagulation and new findings of abnormalities on thromboelastographic testing. Specific coagulopathy profiles including an abnormal vWF/ADAMTS13 ratio may be associated with poor outcome and increased bleeding risk. Use of N-acetylcysteine in nonparacetamol-related cases remains unsupported by robust clinical evidence. New microRNA-based prognostic markers to select patients for transplantation are described but are still far from widespread clinical applicability; imaging-based prognostication tools are also promising. The use of extracorporeal artificial liver devices in clinical practice is yet to be supported by evidence.

Summary: Medical treatment of patients with acute liver failure is now associated with significantly improved survival. Better prognostication and selection for emergency liver transplant may further improve care for these patients.

# 急性肝衰竭。

审查目的：介绍急性肝衰竭的概述，从定义到重症监护管理，根据选定的较新研究结果进行更新。

近期结果：急性肝衰竭患者的生存率逐渐改善。目前，肝性脑病并发颅内高压的频率远低于过去，现在很少使用侵入性 ICP 监测。早期肾脏替代治疗和可能的治疗性血浆置换已证实了其在治疗中的作用。进一步的证据证实，这些患者的出血发生率较低，尽管凝血标准检查有显著异常，血栓弹性成像检查出现异常的新发现。特异性凝血病特征（包括 vWF/ADAMTS13 比值异常）可能与不良结局和出血风险增加相关。稳健的临床证据仍不支持在非对乙酰氨基酚相关病例中使用 N - 乙酰半胱氨酸。描述了新的基于 microRNA 的预后标志物来选择移植患者，但仍远未达到广泛的临床适用性；基于成像的预后工具也很有前景。体外人工肝装置在临床实践中的应用尚待证据支持。

总结：急性肝衰竭患者的药物治疗与生存率显著改善相关。更好的预后和选择急诊肝移植可能进一步改善这些患者的治疗。

期：2 ；页码：198-207； DOI：10.1097/MCC.0000000000000923

# Management of gastrointestinal failure in the adult critical care setting.

Author: Mette Berger, Claire-Anne Hurni

Abstract: Purpose of review: Gastrointestinal failure is a polymorphic syndrome with multiple causes. Managing the different situations from a practical, metabolic, and nutritional point of view is challenging, which the present review will try to address.

Recent findings: Acute gastrointestinal injury (AGI) has been defined and has evolved into a concept of gastrointestinal dysfunction score (GIDS) built on the model of Sequential Organ Failure Assessment (SOFA) score, and ranging from 0 (no risk) to 4 (life threatening). But there is yet no specific, reliable and reproducible, biomarker linked to it. Evaluating the risk with the Nutrition Risk Screening (NRS) score is the first step whenever addressing nutrition therapy. Depending on the severity of the gastrointestinal failure and its clinical manifestations, nutritional management needs to be individualized but always including prevention of undernutrition and dehydration, and administration of target essential micronutrients. The use of fibers in enteral feeding solutions has gained acceptance and is even recommended based on microbiome findings. Parenteral nutrition whether alone or combined to enteral feeding is indicated whenever the intestine is unable to process the needs.

Summary: The heterogeneity of gastrointestinal insufficiency precludes a uniform nutritional management of all critically ill patients but justifies its early detection and the implementation of individualized care.

# 成人重症监护条件下胃肠功能衰竭的管理。

审查目的：胃肠功能衰竭是一种多病因的多形性综合征。从实际、代谢和营养角度管理不同情况具有挑战性，本综述将尝试解决这一问题。

近期结果：急性胃肠道损伤 (AGI) 已经定义，并已经演变为在序贯器官衰竭评估 (SOFA) 评分模型基础上建立的胃肠道功能障碍评分 (GIDS) 的概念，范围从 0（没有风险）至 4（危及生命）。但目前还没有特异性、可靠和可重现的生物标志物与其相关。营养风险筛查 (NRS) 评分是评估营养治疗风险的第一步。根据胃肠功能衰竭的严重程度及其临床表现，营养管理需要个体化，但始终包括预防营养不足和脱水，以及给予目标必需微量营养素。纤维在肠内营养溶液中的应用已获得认可，甚至根据微生物组的结果推荐使用。当肠道无法处理需求时，可单独使用或与肠内喂养联用的肠外营养。

总结：胃肠功能不全的异质性使得无法对所有重症患者进行统一的营养管理，但也证明了早期检测和实施个体化治疗的合理性。

期：2 ；页码：190-197； DOI：10.1097/MCC.0000000000000924

# Liver trauma in the intensive care unit.

Author: Alexandra Hetherington, Filipe Cardoso, Erica Lester, Constantine Karvellas

Abstract: Purpose of review: To review the surgical and critical care management of liver trauma; one of the most common abdominal injuries sustained due to its size and location.

Recent findings: Hepatic injuries range from negligible to life threatening: in the acute phase, the most common cause of morbidity and mortality is hemorrhage; however, severe traumatic hepatic injuries can also lead to biochemical abnormalities, altered coagulation, and ultimately liver failure. This brief review will review the classification of traumatic liver injuries by mechanism, grade, and severity. Most Grades I-III injuries can be managed nonoperatively, whereas the majority of Grades IV-VI injuries require operative management. Therapeutic strategies for traumatic liver injury including nonoperative, operative, radiologic will be described. The primary goal of liver trauma management in the acute setting is hemorrhage control, then the management of secondary factors such as bile leaks. The rapid restoration of homeostasis may prevent further damage to the liver and allow for deferred nonoperative management, which has been shown to be associated with good clinical outcomes.

Summary: A multidisciplinary approach to the care of these patients at an experienced liver surgery center is warranted.

# 重症监护室的肝创伤。

审查目的：审查肝创伤的外科和重症监护管理；由于肝创伤的大小和位置，肝创伤是最常见的腹部损伤之一。

最近的发现：肝损伤的范围从可忽略到危及生命：在急性期，发病和死亡的最常见原因是出血；但是，重度创伤性肝损伤也可导致生化异常、凝血改变，并最终导致肝衰竭。本简要综述将按机制、分级和严重程度对创伤性肝损伤的分类进行综述。大多数 I-III 级损伤可以采用非手术治疗，而大多数 IV-VI 级损伤需要手术治疗。将描述创伤性肝损伤的治疗策略，包括非手术、手术、放射学。急性背景下肝创伤管理的主要目标是出血控制，然后是继发因素（如胆漏）的管理。快速恢复体内平衡可防止对肝脏的进一步损害，并允许延迟非手术治疗，已证实其与良好的临床结局相关。

总结：有必要在有经验的肝脏手术中心对这些患者进行多学科治疗。

期：2 ；页码：184-189； DOI：10.1097/MCC.0000000000000928

# Treating the body to prevent brain injury: lessons learned from the coronavirus disease 2019 pandemic.

Author: Tracey Fan, Veronika Solnicky, Sung-Min Cho

Abstract: Purpose of review: We aim to provide the current evidence on utility and application of neuromonitoring tools including electroencephalography (EEG), transcranial Doppler (TCD), pupillometry, optic nerve sheath diameter (ONSD), cerebral near-infrared spectroscopy (cNIRS), somatosensory-evoked potentials (SSEPs), and invasive intracranial monitoring in COVID-19. We also provide recent evidence on management strategy of COVID-19-associated neurological complications.

Recent findings: Despite the common occurrence of neurological complications, we found limited use of standard neurologic monitoring in patients with COVID-19. No specific EEG pattern was identified in COVID-19. Frontal epileptic discharge was proposed to be a potential marker of COVID-19 encephalopathy. TCD, ONSD, and pupillometry can provide real-time data on intracranial pressure. Additionally, TCD may be useful for detection of acute large vessel occlusions, abnormal cerebral hemodynamics, cerebral emboli, and evolving cerebral edema at bedside. cNIRS was under-utilized in COVID-19 population and there are ongoing studies to investigate whether cerebral oxygenation could be a more useful parameter than peripheral oxygen saturation to guide clinical titration of permissive hypoxemia. Limited data exists on SSEPs and invasive intracranial monitoring.,

Summary: Early recognition using standardized neuromonitoring and timely intervention is important to reduce morbidity and mortality. The management strategy for neurological complications is similar to those without COVID-19.

# 治疗身体以预防脑损伤： 2019 年冠状病毒病大流行的经验教训。

综述目的：我们旨在提供神经监测工具的实用性和应用的当前证据，包括脑电图 (EEG)、经颅多普勒 (TCD)、瞳孔测量、视神经鞘直径 (ONSD)、脑近红外光谱 (cNIRS)、体感诱发电位 (SSEPs) 和 COVID-19 中的侵入性颅内监测。我们还提供了有关 COVID-19 相关神经系统并发症管理策略的最新证据。

最近的发现：尽管常见神经系统并发症，我们发现在 COVID-19 患者中标准神经系统监测的使用有限。在 COVID-19 中未发现特定的 EEG 模式。额叶癫痫性放电被认为是 COVID-19 脑病的潜在标志。TCD、ONSD 和瞳孔测量可提供颅内压的实时数据。此外，TCD 可用于检测急性大血管闭塞、脑血流动力学异常、脑栓塞，以及床边进展性脑水肿。cNIRS 在 COVID-19 人群中使用不足，有正在进行的研究调查脑氧合是否是比外周血氧饱和度更有用的参数，以指导允许性低氧血症的临床滴定。目前关于 SSEP 和侵入性颅内监测的数据有限。,,,,,

总结：早期识别使用标准化的神经监测和及时干预对降低发病率和死亡率很重要。神经系统并发症的管理策略与无 COVID-19 的相似。

期：2 ；页码：176-183； DOI：10.1097/MCC.0000000000000917

# Acute traumatic brain injury in frail patients: the next pandemic.

Author: Marta Baggiani, Angelo Guglielmi, Giuseppe Citerio

Abstract: Purpose of review: To highlight recent findings on the evaluation and impact of frailty in the management of patients with traumatic brain injury (TBI).

Recent findings: Frailty is not a direct natural consequence of aging. Rather, it commonly results from the intersection of age-related decline with chronic diseases and conditions. It is associated with adverse outcomes such as institutionalization, falls, and worsening health status. Growing evidence suggests that frailty should be a key consideration both in care planning and in adverse outcome prevention. The prevalence of elderly patients with TBI is increasing, and low-energy trauma (i.e., ground or low-level falls, which are typical in frail patients) is the major cause. Establishing the real incidence of frailty in TBI requires further studies. Failure to detect frailty potentially exposes patients to interventions that may not benefit them, and may even harm them. Moreover, considering patients as 'nonfrail' purely on the basis of their age is unacceptable. The future challenge is to shift to a new clinical paradigm characterized by more appropriate, goal-directed care of frail patients.

Summary: The current review highlights the crucial importance of frailty evaluation in TBI, also given the changing epidemiology of this condition. To ensure adequate assessment, prevention and management, both in and outside hospital, there is an urgent need for a valid screening tool and a specific frailty-based and comorbidity-based clinical approach.

# 虚弱患者的急性创伤性脑损伤：下一次大流行

综述目的：强调有关虚弱在创伤性脑损伤 (TBI) 患者管理中的评价和影响的最新结果。

最新研究结果：虚弱不是衰老的直接自然结果。相反，它通常是年龄相关的下降与慢性疾病和状况交集的结果。它与不良结局相关，如收容、跌倒和健康状况恶化。越来越多的证据表明，虚弱应成为护理计划和不良结局预防的关键考虑因素。老年 TBI 患者的患病率不断增加，低能量创伤（即，在虚弱患者中典型的地面或低水平跌倒）是主要原因。确定 TBI 中虚弱的真实发生率需要进一步研究。未检测到虚弱可能使患者暴露于可能对其无益的干预，甚至可能对其造成伤害。此外，单纯根据患者的年龄将其视为 “非虚弱” 是不可接受的。未来的挑战是转变为一种新的临床模式，以对虚弱患者进行更适当的目标导向护理为特征。

总结：本综述强调了 TBI 中虚弱评估的关键重要性，同时考虑到这种疾病的流行病学变化。为了确保在医院内和医院外进行充分的评估、预防和管理，迫切需要一种有效的筛查工具和一种特定的基于脆弱和基于共病的临床方法。

期：2 ；页码：166-175； DOI：10.1097/MCC.0000000000000915

# The intensive care management of acute ischaemic stroke.

Author: Deepak Sharma, Martin Smith

Abstract: Purpose of review: To discuss recent advances in the critical care management of acute ischaemic stroke patients and highlight controversies and consensus.

Recent findings: Intravenous thrombolysis and endovascular thrombectomy are standard of care reperfusion therapies that have revolutionized the management of acute ischaemic stroke and transformed outcomes for patients. They can now be delivered in extended time windows and to those previously ineligible for intervention based on advanced neuroimaging criteria. Secondary systemic insults, such as hypo- and hypertension, hyperthermia or hyperglycaemia, which can extend the area of ischaemia must also be prevented or corrected to minimize infarct progression. Meticulous blood pressure management is of central importance, particularly in patients that have undergone reperfusion therapies. Neurological deterioration can occur because of infarct extension, haemorrhagic transformation or worsening cerebral oedema. Transcranial Doppler ultrasonography allows bedside, noninvasive evaluation of cerebral haemodynamics and is increasingly used in acute stroke triage, management and recovery prediction. The management of acute ischaemic stroke raises several ethical issues, and shared decision making is essential to ensure outcomes that are compatible with an individual patient's expectations.

Summary: A bundle of medical, endovascular and surgical strategies implemented by a multidisciplinary team working to locally agreed protocols can improve long-term stroke outcomes.

# 急性缺血性脑卒中的重症监护管理。

综述目的：讨论急性缺血性脑卒中患者重症监护管理的最新进展，并强调争议和共识。

最近的结果：静脉溶栓和血管内血栓切除术是再灌注治疗的标准疗法，彻底改变了急性缺血性卒中的管理和患者结局的变化。现在可以在延长的时间窗内提交，并且根据先进的神经影像学标准，提供给既往不适合干预的患者。还必须预防或纠正可延长缺血面积的继发性全身性损伤，如低血压和高血压、高热或高血糖，以尽量减少梗死进展。细致的血压管理至关重要，尤其是在接受再灌注治疗的患者中。由于梗塞范围扩大、出血性转化或脑水肿恶化，可能发生神经功能恶化。经颅多普勒超声允许对脑血流动力学进行床旁无创评估，越来越多地用于急性卒中的分诊、管理和恢复预测。急性缺血性卒中的管理引发了多个伦理问题，共同决策制定对于确保结局符合个体患者的预期至关重要。

总结：由多学科团队按照当地商定的方案实施的一组内科、血管内和外科策略可改善长期卒中结局。

期：2 ；页码：157-165； DOI：10.1097/MCC.0000000000000912

# Optimizing oxygen delivery to the injured brain.

Author: Shaurya Taran, Paolo Pelosi, Chiara Robba

Abstract: Purpose of review: The principle of optimizing oxygen delivery to the injured brain rests on the premise that both hypoxia and hyperoxia are important mediators of secondary brain injury and should be avoided. This rationale has prompted a move towards incorporating oxygenation endpoints into the management of neurocritical care patients, particularly those with traumatic brain injury. The present review will seek to describe clinical strategies to optimize oxygenation in the acutely brain-injured patient, drawing upon relevant physiologic principles and clinical data, where it exists.

Recent findings: A phase II randomized trial found that a protocolized approach to improving oxygen delivery resulted in less duration of brain hypoxia and a trend towards lower mortality among patients with severe traumatic brain injury. Recent clinical protocols have been published to guide oxygen delivery based on core physiologic principles: increasing oxygen supply via modulation of mean arterial pressure and intracranial pressure, blood oxygen carrying capacity, and cerebral vasoreactivity; and decreasing oxygen demand via sedation, pharmacologic coma, and hypothermia.

Summary: Although there is growing interest in the use of brain tissue oxygenation as a resuscitative endpoint, many of these therapies are based on physiologic principles with little robust clinical evidence to guide their application. Clinicians must be mindful of this and balance the putative benefits of improving oxygenation against the risks associated with the use of such therapies.

# 优化损伤大脑的氧气输送。

综述目的：对损伤脑组织进行优化供氧的原理在于，缺氧和高氧均为继发性脑损伤的重要介质，应避免这两种情况的发生。这一原理促使人们逐渐将氧合终点纳入神经重症监护患者的管理，尤其是创伤性脑损伤患者。本综述将利用相关的生理学原理和临床数据（如果存在），试图描述优化急性脑损伤患者氧合的临床策略。

近期结果：一项 II 期随机试验发现，改善氧输送的方案化方法导致重度创伤性脑损伤患者的脑缺氧持续时间缩短，死亡率降低。已发表了基于核心生理学原理的近期临床方案，以指导氧气输送：通过调节平均动脉压和颅内压、血氧携带能力和脑血管反应性增加氧气供应；通过镇静、药理学昏迷和低温降低需氧量。

总结：虽然人们越来越关注将脑组织氧合作为复苏终点，但其中许多治疗是基于生理学原理，几乎没有可靠的临床证据来指导其应用。临床医生必须注意这一点，并权衡改善氧合的假定获益与使用此类治疗相关的风险。

期：2 ；页码：145-156； DOI：10.1097/MCC.0000000000000913

# Challenges in the hemodynamic management of acute nontraumatic neurological injuries.

Author: Antonio Messina, Federico Villa, Maurizio Cecconi

Abstract: Purpose of review: To appraise the evidence from the literature and suggest an integrated hemodynamic approach of early and delayed phases of acute ischemic stroke (AIS), subarachnoid hemorrhage (SAH) and intracerebral hemorrhage (ICH).

Recent findings: In AIS, the research aims to evaluate the optimal pressure control before, during and after the revascularization, to optimize the perfusion in the ischemic areas, minimizing the risk of hemorrhage or secondary damage to already infarcted areas. In the early phase of SAH, systemic pressure should be controlled to balance the risk of stroke, hypertension-related rebleeding, and maintenance of cerebral perfusion pressure. The late phase aims to minimize the risk of cerebral vasospasm by adapting systemic pressure and volemia to cerebral and systemic physiological hemodynamic targets. In the mild-to-moderate ICH, achieving SAP of less than 140 mmHg and greater than 110 mmHg may be considered as a beneficial target. Caution should be considered in lowering intensively SAP in severe ICH.

Summary: In nontraumatic brain injuries, the hemodynamic management is strictly related to fluctuating physiology of these diseases, needing a strict control of pressure and flow variable to ensure both cerebral and systemic homeostasis.

# 急性非创伤性神经损伤血液动力学管理的挑战。

综述目的：评价文献中的证据，并提出急性缺血性卒中 (AIS)、蛛网膜下腔出血 (SAH) 和脑出血 (ICH) 早期和延迟期的综合血液动力学方法。

最新结果：在 AIS 中，研究旨在评价血运重建前、血运重建中和血运重建后的最佳压力控制，优化缺血区域的灌注，将出血或对已梗死区域的继发性损伤风险降至最低。在 SAH 的早期阶段，应控制体循环压力以平衡卒中、高血压相关再出血的风险和维持脑灌注压。晚期阶段旨在通过使体循环压力和血容量适应于脑和系统生理血流动力学目标，将脑血管痉挛的风险降至最低。在轻中度 ICH 中，认为达到低于 140 mmHg 和高于 110 mmHg 的 SAP 是有益目标。在重度 ICH 中强化降低 SAP 时应谨慎。

总结：在非创伤性脑损伤中，血流动力学管理与这些疾病的生理波动严格相关，需要严格控制压力和流量变量，以确保脑和全身稳态。

期：2 ；页码：138-144； DOI：10.1097/MCC.0000000000000925

# Fever management in acute brain injury.

Author: Elisa Bogossian, Fabio Taccone

Abstract: Purpose of review: Fever is common after acute brain injury and is associated with poor prognosis in this setting.

Recent findings: Achieving normothermia is feasible in patients with ischemic or hemorrhagic strok. subarachnoid hemorrhage and traumatic brain injury. Pharmacological strategies (i.e. paracetamol or nonsteroidal anti-inflammatory drugs) are frequently ineffective and physical (i.e. cooling devices) therapies are often required. There are no good quality data supporting any benefit from therapeutic strategies aiming at normothermia in all brain injured patients when compared with standard of car. where mild-to-moderate fever is tolerated. Howeve. recent guidelines recommended fever control in this setting.

Summary: As fever is considered a clinically relevant secondary brain damag. we have provided an individualized therapeutic approach to treat it in brain injured patient. which deserved further validation in the clinical setting.

# 急性脑损伤的发热管理。

综述目的：发热在急性脑损伤后很常见，在这种情况下与不良预后相关。

最近的发现：在缺血性或出血性卒中、蛛网膜下腔出血和创伤性脑损伤患者中实现正常体温是可行的。药物策略（即，对乙酰氨基酚或非甾体抗炎药）通常无效，通常需要物理（即，冷却装置）治疗。与标准治疗（轻度至中度发热可耐受）相比，尚无高质量数据支持所有脑损伤患者从旨在达到正常体温的治疗策略中获益。然而，最近的指南建议在这种情况下控制发热。

总结：由于发热被认为是一种临床相关的继发性脑损伤，我们提供了一种个体化的治疗方法来治疗脑损伤患者，值得在临床环境中进一步验证。

期：2 ；页码：130-137； DOI：10.1097/MCC.0000000000000918

# Individualized cerebral perfusion pressure in acute neurological injury: are we ready for clinical use?.

Author: Miriam Weis. Geert Meyfroid. Marcel Aries

Abstract: Purpose of review: Individualizing cerebral perfusion pressure based on cerebrovascular autoregulation assessment is a promising concept for neurological injuries where autoregulation is typically impaired. The purpose of this review is to describe the status quo of autoregulation-guided protocols and discuss steps towards clinical use.

Recent findings: Retrospective studies have indicated an association of impaired autoregulation and poor clinical outcome in traumatic brain injury (TBI. hypoxic-ischemic brain injury (HIBI) and aneurysmal subarachnoid hemorrhage (aSAH). The feasibility and safety to target a cerebral perfusion pressure optimal for cerebral autoregulation (CPPopt) after TBI was recently assessed by the COGITATE trial. Similarl. the feasibility to calculate a MAP target (MAPopt) based on near-infrared spectroscopy was demonstrated for HIBI. Failure to meet CPPopt is associated with the occurrence of delayed cerebral ischemia in aSAH but interventional trials in this population are lacking. No level I evidence is available on potential effects of autoregulation-guided protocols on clinical outcomes.

Summary: The effect of autoregulation-guided management on patient outcomes must still be demonstrated in prospectiv. randomize. controlled trials. Selection of disease-specific protocols and endpoints may serve to evaluate the overall benefit from such approaches.

# 急性神经损伤的个体化脑灌注压：我们是否准备好用于临床？

综述目的：基于脑血管自动调节评估的个体化脑灌注压是自动调节通常受损的神经损伤的一个有前景的概念。本综述的目的是描述自动调节引导方案的现状，并讨论临床使用的步骤。

最近的研究结果：回顾性研究表明，创伤性脑损伤 (TBI)、缺氧缺血性脑损伤 (HIBI) 和动脉瘤性蛛网膜下腔出血 (aSAH) 的自动调节受损与不良临床结局相关。最近通过 COGITATE 试验评估了 TBI 后靶向脑自动调节最佳脑灌注压 (CPPopt) 的可行性和安全性。同样，证明了基于近红外光谱计算 HIBI MAP 目标 (MAPopt) 的可行性。不符合 CPPopt 与 aSAH 迟发性脑缺血的发生有关，但缺乏在该人群中进行的干预性试验。尚无关于自动调节引导方案对临床结局潜在影响的 I 级证据。

总结：自动调节引导治疗对患者结局的影响仍必须在前瞻性、随机、对照试验中证实。疾病特异性方案和终点的选择可用于评价此类方法的总体获益。

期：2 ；页码：123-129； DOI：10.1097/MCC.0000000000000919

# How to manage traumatic brain injury without invasive monitoring?.

Author: Daniel Godo. Alejandro Rabinstein

Abstract: Purpose of review: Severe traumatic brain injury (TBI) is an extremely serious health proble. especially in low-middle income countries (LMICs). The prevalence of severe TBI continues to increase in LMICs. Major limitations in the chain of care for TBI patients are common in LMICs including suboptimal or nonexistent prehospital car. overburdened emergency service. lack of trained human resources and limited availability of ICUs. Basic neuromonitorin. such as intracranial pressur. are unavailable or underutilized and advanced techniques are not available.

Recent findings: Attention to fundamental principles of TBI care in LMIC. including early categorizatio. prevention and treatment of secondary insult. use of low-cost technology for evaluation of intracranial bleeding and neuromonitorin. and emphasis on education of human resources and multidisciplinary wor. are particularly important in LMICs. Institutional collaborations between high-income and LMICs have developed evidence focused on available resources. Accordingl. an expert group have proposed consensus recommendations for centers without availability of invasive brain monitoring.

Summary: Severe TBI is very prevalent in LMIC and neuromonitoring is often not available in these environments. When intracranial pressure monitors are not availabl. careful attention to changes on clinical examinatio. serial imaging and noninvasive monitoring techniques can help recognize intracranial hypertension and effectively guide treatment decisions.

# 如何在无创监测的情况下管理创伤性脑损伤？

综述目的：严重创伤性脑损伤 (TBI) 是一个极其严重的健康问题，尤其是在中低收入国家 (LMIC)。严重 TBI 的患病率在 LMIC 中持续增加。TBI 患者护理链的主要局限性在 LMIC 中很常见，包括院前护理欠佳或不存在、急救服务负担过重、缺乏经过培训的人力资源和 ICU 可用性有限。基本神经监测，如颅内压，不可用或使用不足，无法获得先进技术。

最近的研究结果：在中等收入国家注意 TBI 护理的基本原则，包括早期分类、预防和治疗继发性损伤、使用低成本技术评估颅内出血和神经监测、强调人力资源教育和多学科工作，在中等收入国家尤其重要。高收入国家和中等收入国家之间的机构合作已经形成了侧重于现有资源的证据。因此，一个专家组提出了对无法进行侵入性脑监测的中心的共识建议。

总结：严重 TBI 在 LMIC 中非常普遍，在这些环境中通常无法进行神经监测。当颅内压监测仪不可用时，仔细关注临床检查、系列成像和无创监测技术上的变化，可以帮助认识颅内高压，有效指导治疗决策。

期：2 ；页码：111-122； DOI：10.1097/MCC.0000000000000914

# Intracranial pressure management: moving beyond guidelines.

Author: Andres Rubian. Anthony Figaj. Gregory Hawryluk

Abstract: Purpose of review: The aim of this study was to provide an overview on advances in intracranial pressure (ICP) protocols for car. moving from traditional to more recent concepts.

Recent findings: Deep understanding of mechanics and dynamics of fluids and solids have been introduced for intracranial physiology. The amplitude or the harmonics of the cerebral-spinal fluid and the cerebral blood waves shows more information about ICP than just a numeric threshold. When the ICP overcome the compensatory mechanisms that maintain the compliance within the skul. an intracranial compartment syndrome (ICCS) is defined. Autoregulation monitoring emerge as critical tool to recognize CPP management. Measurement of brain tissue oxygen will be a critical intervention for diagnosing an ICCS. Surgical procedures focused on increasing the physiological compliance and increasing the volume of the compartments of the skull.

Summary: ICP management is a complex tas. moving far than numeric thresholds for activation of interventions. The interactions of intracranial elements requires new interpretations moving beyond classical theories. Most of the traditional clinical studies supporting ICP management are not generating high class evidence. Recommendations for ICP management requires better designed clinical studies using new concepts to generate interventions according to the new era of personalized medicine.

# 颅内压管理：超出指南范围。

综述目的：本研究的目的是提供颅内压 (ICP) 护理方案进展的概述，从传统概念转变为更新的概念。

最近的发现：对颅内生理学中液体和固体的力学和动力学有了深入的了解。脑脊液和脑血液波的振幅或谐波显示的 ICP 信息比数字阈值更多。当 ICP 克服了维持颅骨内顺应性的代偿机制时，定义为颅内间隔室综合征 (ICCS)。自动调节监测已成为识别 CPP 管理的关键工具。脑组织氧测量将是诊断 ICCS 的关键干预措施。外科手术的重点是增加生理顺应性和增加颅骨隔室的体积。

总结：颅内压管理是一项复杂的任务，远远超过干预激活的数字阈值。颅内元素的相互作用需要超越经典理论的新解释。支持 ICP 管理的大多数传统临床研究未产生高级证据。颅内压管理的建议要求根据个体化医疗的新时代，使用新概念进行更好设计的临床研究，以产生干预措施。

期：2 ；页码：101-110； DOI：10.1097/MCC.0000000000000920

# Editorial: Effective treatments for acute neurological injury: are we moving forward?.

Author: Chiara Robba

# 社论：急性神经损伤的有效治疗方法：我们是否在继续？

期：2 ；页码：99-100； DOI：10.1097/MCC.0000000000000916

Author: Briana Shor. Darryl Abram. Daniel Brodie

Abstract: Purpose of review: To understand the potential role of extracorporeal membrane oxygenation (ECMO) in coronavirus disease 2019 (COVID-19)-related acute respiratory distress syndrome (ARDS. highlighting evolving practices and outcomes.

Recent findings: The role for ECMO in COVID-19-related ARDS has evolved throughout the pandemic. Early reports of high mortality led to some to advocate for withholding ECMO in this setting. Subsequent data suggested mortality rates were on par with those from studies conducted prior to the pandemic. Howeve. outcomes are evolving and mortality in these patients may be worsening with time.

Summary: ECMO has an established role in the treatment of severe forms of ARDS. Current data suggest adherence to the currently accepted algorithm for management of ARD. including the use of ECMO. Howeve. planning related to resource utilization and strain on healthcare systems are necessary to determine the feasibility of ECMO in specific regions at any given time. Utilization of national and local network. pooling of resources and ECMO mobilization units are important to optimize access to ECMO as appropriate. Reported complications of ECMO in the setting of COVID-19-related ARDS have been predominantly similar to those reported in studies of non-COVID-19-related ARDS. Further high-quality research is needed.

# 体外膜肺氧合治疗 2019 年冠状病毒病相关的急性呼吸窘迫综合征。

审查目的：了解体外膜肺氧合 (ECMO) 在 2019 年冠状病毒病 (COVID-19) 相关急性呼吸窘迫综合征 (ARDS) 中的潜在作用，强调不断变化的实践和结局。

最近的发现：ECMO 在 COVID-19 相关 ARDS 中的作用在整个大流行过程中不断演变。早期报告的高死亡率导致一些人主张在这种情况下暂停 ECMO。随后的数据表明，死亡率与大流行前进行的研究结果持平。但是，结局不断变化，这些患者的死亡率可能随时间推移而恶化。

总结：ECMO 在治疗严重 ARDS 中具有明确的作用。当前数据表明，遵循目前公认的 ARDS 管理方案，包括使用 ECMO。然而，为了在任何给定时间确定 ECMO 在特定地区的可行性，需要制定与资源利用和医疗保健系统压力相关的计划。利用国家和地方网络，汇集资源和 ECMO 动员单位，对酌情优化 ECMO 准入很重要。在 COVID-19 相关 ARDS 背景下报告的 ECMO 并发症主要与非 COVID-19 相关 ARDS 研究报告的并发症相似。需要进一步高质量的研究。

期：1 ；页码：90-97； DOI：10.1097/MCC.0000000000000901

# Coronavirus disease 2019 in immunocompromised patients: a comprehensive review of coronavirus disease 2019 in hematopoietic stem cell recipients.

Author: Antoine Lafarg. Asma Mabrouk. Elise Yvi. Swann Bredi. Yannick Binoi. Raphael Clere-Jeh. Elie Azoulay

Abstract: Purpose of review: Immunocompromised patients are notably vulnerable to severe coronavirus disease 2019. This review summarizes COVID-19 features and outcomes in autologous and allogeneic hematopoietic stem cell transplantation (HSCT) recipients.

Recent findings: Recent findings suggest that HSCT recipients exhibit a high burden of comorbidities and COVID-19 clinical features almost similar to the general COVID population. Furthermor. HSCT recipients exhibit a protracted SARS-CoV-2 sheddin. prolonging duration of symptoms and promoting the generation of highly mutated viruses. Las. most of studies report a higher COVID-19 mortality in HSCT recipient. mainly driven by ag. comorbiditie. time from transplantatio. and immunosuppression because of both treatments and underlying hematological malignancy.

Summary: Further studies are warranted to determine the proper impact of HSCT-related immune disorders on COVID-19 outcome. and to evaluate specific treatments and vaccination strategy in this high-risk population. Taken togethe. those findings emphasize the need for more rigorous surveillance and preemptive measures for all HSCT recipients.

# 2019 年免疫功能低下患者中的冠状病毒病：一项对 2019 年造血干细胞接受者中冠状病毒病的全面审查。

审查目的：免疫功能低下患者特别容易发生严重的冠状病毒病 2019。本综述总结了自体和异体造血干细胞移植 (HSCT) 接受者的 COVID-19 特征和结局。

最近的发现：最近的发现表明，HSCT 接受者表现出高负担的合并症和 COVID-19 临床特征与一般 COVID 人群几乎相似。此外，HSCT 受体表现出长期的 SARS-CoV-2 脱落，延长症状持续时间并促进产生高度突变的病毒。最后，大多数研究报告 HSCT 接受者的 COVID-19 死亡率更高，这主要是由于年龄、合并症、距移植的时间和因两种治疗和基础血液恶性肿瘤导致的免疫抑制所致。

总结：有必要进行进一步研究，以确定 HSCT 相关免疫疾病对 COVID-19 结局的适当影响，并评估该高风险人群的特异性治疗和疫苗接种策略。总之，这些结果强调了对所有 HSCT 接受者进行更严格的监测和先发制人措施的必要性。

期：1 ；页码：83-89； DOI：10.1097/MCC.0000000000000907

# Ventilator-associated pneumonia among SARS-CoV-2 acute respiratory distress syndrome patients.

Author: Jacopo Fumagall. Mauro Panigad. Michael Klompa. Lorenzo Berra

Abstract: Purpose of review: We conducted a systematic literature review to summarize the available evidence regarding the incidenc. risk factor. and clinical characteristics of ventilator-associated pneumonia (VAP) in patients undergoing mechanical ventilation because of acute respiratory distress syndrome secondary to SARS-CoV-2 infection (C-ARDS).

Recent findings: Sixteen studies (6484 patients) were identified. Bacterial coinfection was uncommon at baseline (<15%) but a high proportion of patients developed positive bacterial cultures thereafter leading to a VAP diagnosis (range 21-64. weighted average 50%). Diagnostic criteria varied between studies but most signs of VAP have substantial overlap with the signs of C-ARDS making it difficult to differentiate between bacterial colonization versus superinfection. Most episodes of VAP were associated with Gram-negative bacteria. Occasional cases were also attributed to herpes virus reactivations and pulmonary aspergillosis. Potential factors driving high VAP incidence rates include immunoparalysi. prolonged ventilatio. exposure to immunosuppressant. understaffin. lapses in prevention processe. and overdiagnosis.

Summary: Covid-19 patients who require mechanical ventilation for ARDS have a high risk (>50%) of developing VA. most commonly because of Gram-negative bacteria. Further work is needed to elucidate the disease-specific risk factors for VA. strategies for preventio. and how best to differentiate between bacterial colonization versus superinfection.

# SARS-CoV-2 急性呼吸窘迫综合征患者中的呼吸机相关性肺炎。

综述目的：我们进行了系统的文献综述，以总结关于因 SARS-CoV-2 感染 (C-ARDS) 继发急性呼吸窘迫综合征而接受机械通气的患者中呼吸机相关性肺炎 (VAP) 的发生率、风险因素和临床特征的现有证据。

近期结果：确定了 16 项研究（6484 例患者）。基线时细菌合并感染不常见 (<15%)，但是之后出现导致 VAP 诊断的阳性细菌培养的患者比例高（范围 21-64%，加权平均值 50%）。研究之间的诊断标准各不相同，但大多数 VAP 体征与 C-ARDS 体征有大量重叠，使得难以区分细菌定植与二重感染。大多数 VAP 发作与革兰氏阴性菌相关。偶尔病例也可归因于疱疹病毒再激活和肺曲霉病。驱动高 VAP 发生率的潜在因素包括免疫麻痹、长时间通气、免疫抑制剂暴露、谈话、预防过程失误和过度诊断。

总结：Covid-19 因 ARDS 而需要机械通气的患者发生 VAP 的风险较高 (> 50%)，最常见的原因是革兰氏阴性菌。需要进一步的工作来阐明 VAP 的疾病特异性风险因素、预防策略以及如何最好地鉴别细菌定植与二重感染。

期：1 ；页码：74-82； DOI：10.1097/MCC.0000000000000908

# Advanced respiratory monitoring in mechanically ventilated patients with coronavirus disease 2019-associated acute respiratory distress syndrome.

Author: Peter Somhors. Diederik Gommer. Henrik Endeman

Abstract: Purpose of review: To summarize the current knowledge about the application of advanced monitoring techniques in coronavirus disease 2019 (COVID-19).

Recent findings: Due to the heterogeneity between patient. management of COVID-19 requires daily monitoring of and/or aeration and inspiratory effort. Electrical impedance tomography can be used to optimize positive end-expiratory pressur. monitor the response to changes in treatment or body position and assess pulmonary perfusion and ventilation/perfusion matching. Lung ultrasound is more readily available and can be used to measure and monitor recruitmen. provide an indication of diaphragm function and pulmonary perfusion disturbances. Esophageal pressure measurements enable the calculation of the transpulmonary pressure and inspiratory effort in order to prevent excessive stress on the lung. While esophageal pressure measurements are the golden standard in determining inspiratory effor. alternatives like P0.. negative pressure swing during a single airway occlusion and change in central venous pressure are more readily available and capable of diagnosing extreme inspiratory efforts.

Summary: Although there is little data on the effectiveness of advanced monitoring techniques in COVID-1. regular monitoring should be a central part of the management of COVID-19-related acute respiratory distress syndrome (C-ARDS).

# 在 2019 年伴有急性呼吸窘迫综合征的冠状病毒病机械通气患者中的高级呼吸监测。

审查目的：总结有关先进监测技术在 2019 年冠状病毒病 (COVID-19) 中应用的当前知识。

最新结果：由于患者之间的异质性，COVID-19 的管理需要每日监测和 / 或通气和吸气努力。电阻抗断层成像可用于优化呼气末正压，监测对治疗或体位变化的反应，并评估肺灌注和通气 / 灌注匹配。肺部超声更容易获得，可用于测量和监测肺复张，提供膈肌功能和肺灌注障碍的适应症。食管压力测量能够计算跨肺压和吸气努力度，以防止对肺过度施加压力。虽然食管压力测量是确定吸气努力的黄金标准，但是更容易获得替代方法，如 P0.1，单气道阻塞期间的负压波动和中心静脉压的变化，并能够诊断极度吸气努力。

总结：虽然 COVID-19 中先进监测技术的有效性数据很少，但是常规监测应该是 COVID-19 相关急性呼吸窘迫综合征 (C-ARDS) 管理的核心部分。

期：1 ；页码：66-73； DOI：10.1097/MCC.0000000000000905

# Prone position in COVID 19-associated acute respiratory failure.

Author: Aileen Khara. Marie Simo. Claude Guerin

Abstract: Purpose of review: Prone position has been widely used in the COVID-19 pandemi. with an extension of its use in patients with spontaneous breathing ('awake prone'). We herein propose a review of the current literature on prone position in mechanical ventilation and while spontaneous breathing in patients with COVID-19 pneumonia or COVID-19 ARDS.

Recent findings: A literature search retrieved 70 studies separating whether patient was intubated (24 studies) or nonintubated (46 studies). The outcomes analyzed were intubation rat. mortality and respiratory response to prone. In nonintubated patient receiving prone positio. the main finding was mortality reduction in ICU and outside ICU setting.

Summary: The final results of the several randomized control trials completed or ongoing are needed to confirm the trend of these results. In intubated patient. observational studies showed that responders to prone in terms of oxygenation had a better survival than nonresponders.

# COVID 19 相关性急性呼吸衰竭的俯卧位。

审查目的：俯卧位已广泛用于 COVID-19 大流行，并扩展用于自主呼吸患者（“清醒俯卧”）。我们在此提出对目前 COVID-19 肺炎或 COVID-19 ARDS 患者在机械通气和自主呼吸时采用俯卧位的文献进行综述。

近期结果：文献检索检出 70 项研究，区分了患者是插管（24 项研究）还是非插管（46 项研究）。分析的结局为插管率、死亡率和俯卧位呼吸反应。

总结：需要已完成或正在进行的几项随机对照试验的最终结果来证实这些结果的趋势。在插管患者中，观察性研究显示，氧合倾向应答者的生存期优于无应答者。

期：1 ；页码：57-65； DOI：10.1097/MCC.0000000000000900

Author: Chiara Meg. Irene Cavall. Vito Ranier. Tommaso Tonetti

Abstract: Purpose of review: To review current evidence on the pathophysiology of COVID-19-related acute respiratory distress syndrome (ARDS) and on the implementation of lung protective ventilation.

Recent findings: Although multiple observations and physiological studies seem to show a different pathophysiological behaviour in COVID-19-ARDS compared with 'classical' ARD. numerous studies on thousands of patients do not confirm these findings and COVID-19-ARDS indeed shares similar characteristics and interindividual heterogeneity with ARDS from other causes. Although still scarc. present evidence on the application of lung protective ventilation in COVID-19-ARDS shows that it is indeed consistently applied in ICUs worldwide with a possible signal towards better survival at least in one study. The levels of positive end-expiratory pressure (PEEP) usually applied in these patients are higher than in 'classical' ARD. proposing once again the issue of PEEP personalization in hypoxemic patients. In the absence of robust evidenc. careful evaluation of the patient is neede. and empiric settings should be oriented towards lower levels of PEEP.

Summary: According to the present evidenc. a lung protective strategy based on low tidal volume and plateau pressures is indicated in COVID-19-ARDS as in ARDS from other causes; howeve. there are still uncertainties on the appropriate levels of PEEP.

# 急性呼吸窘迫综合征患者中与 COVID-19 相关的保护性通气：总是、有时或从不？

审查目的：审查 COVID-19 相关急性呼吸窘迫综合征 (ARDS) 病理生理学和肺保护性通气实施的现有证据。

近期结果：虽然多项观察结果和生理学研究似乎显示 COVID-19-ARDS 的病理生理学行为与 “经典” ARDS 不同，对数千例患者的大量研究未证实这些结果，COVID-19-ARDS 确实具有与其他原因所致 ARDS 相似的特征和个体间异质性。虽然目前仍然缺乏，但 COVID-19-ARDS 中应用肺保护通气的证据显示，它确实一致应用于全球 ICU，至少在一项研究中可能有改善生存的信号。这些患者通常应用的呼气末正压 (PEEP) 水平高于 “经典” ARDS，再次提出低氧血症患者 PEEP 个性化的问题。在缺乏有力证据的情况下，需要对患者进行仔细评估，经验设置应针对较低水平的 PEEP。

总结：根据现有证据，COVID-19-ARDS 中基于低潮气量和平台压的肺保护策略适用于其他原因导致的 ARDS；然而，PEEP 的适当水平仍存在不确定性。

期：1 ；页码：51-56； DOI：10.1097/MCC.0000000000000904

# Noninvasive respiratory support for acute respiratory failure due to COVID-19.

Author: Luca Meng. Cecilia Berard. Ersilia Ruggier. Domenico Griec. Massimo Antonelli

Abstract: Purpose of review: Noninvasive respiratory support has been widely applied during the COVID-19 pandemic. We provide a narrative review on the benefits and possible harms of noninvasive respiratory support for COVID-19 respiratory failure.

Recent findings: Maintenance of spontaneous breathing by means of noninvasive respiratory support in hypoxemic patients with vigorous spontaneous effort carries the risk of patient self-induced lung injury: the benefit of averting intubation in successful patients should be balanced with the harms of a worse outcome in patients who are intubated after failing a trial of noninvasive support. The risk of noninvasive treatment failure is greater in patients with the most severe oxygenation impairment (PaO2/FiO2 < 200 mmHg). High-flow nasal oxygen (HFNO) is the most widely applied intervention in COVID-19 patients with hypoxemic respiratory failure. Als. noninvasive ventilation (NIV) and continuous positive airway pressure delivered with different interfaces have been used with variable success rates. A single randomized trial showed lower need for intubation in patients receiving helmet NIV with specific setting. compared to HFNO alone. Prone positioning is recommended for moderate-to-severe acute respiratory distress syndrome patients on invasive ventilation. Awake prone position has been frequently applied in COVID-19 patients: one randomized trial showed improved oxygenation and lower intubation rate in patients receiving 6-h sessions of awake prone positionin. as compared to conventional management.

Summary: Noninvasive respiratory support and awake prone position are tools possibly capable of averting endotracheal intubation in COVID-19 patients; carefully monitoring during any treatment is warranted to avoid delays in endotracheal intubatio. especially in patients with PaO2/FiO2 < 200 mmHg.

# 无创呼吸支持治疗 COVID-19 引起的急性呼吸衰竭。

审查目的：无创呼吸支持在 COVID-19 大流行期间已广泛应用。我们对 COVID-19 呼吸衰竭非侵入性呼吸支持的益处和可能的危害进行了叙述性综述。

最近的发现：在伴有剧烈自主呼吸的低氧血症患者中，通过非侵入性呼吸支持方式维持自主呼吸伴有患者自我诱导的肺损伤风险：在成功的患者中避免插管的获益应与接受插管的患者中更差结局的危害平衡 %__%，无创支持试验失败后。在最严重的氧合障碍患者中 (PaO2/FiO2 < 200 mmHg)，无创治疗失败的风险更大。高流量鼻氧 (HFNO) 是 COVID-19 低氧性呼吸衰竭患者中应用最广泛的干预措施。此外，无创通气 (NIV) 和通过不同接口提供的持续气道正压通气已被用于不同的成功率。一项随机化试验表明，与仅使用 HFNO 相比，在接受特定设置的头罩 NIV 的患者中插管的需求更低。建议对有创通气的中重度急性呼吸窘迫综合征患者进行俯卧位。在 COVID-19 患者中频繁应用清醒俯卧位：一项随机试验表明，与常规管理相比，接受 6h 清醒俯卧位的患者氧合改善，插管率降低。

总结：无创呼吸支持和清醒俯卧位是 COVID-19 患者中可能避免气管插管的工具；在任何治疗期间仔细监测是必要的，以避免气管插管延迟，特别是在 PaO2/FiO2 < 200 mmHg.

期：1 ；页码：25-50； DOI：10.1097/MCC.0000000000000902

# Chest imaging in patients with acute respiratory failure because of coronavirus disease 2019.

Author: Letizia Di Megli. Serena Carrier. Pierpaolo Biondett. Bradford Woo. Gianpaolo Carrafiello

Abstract: Purpose of review: This review aims to explore the different imaging modalitie. such as chest radiography (CXR. computed tomography (CT. ultrasoun. PET/CT sca. and MRI to describe the main features for the evaluation of the chest in COVID-19 patients with ARDS.

Recent findings: This article includes a systematic literature searc. evidencing the different chest imaging modalities used in patients with ARDS from COVID-19. Literature evidences different possible approaches going from the conventional CXR and CT to the LU. MR. and PET/CT.

Summary: CT is the technique with higher sensitivity and definition for studying chest in COVID-19 patients. LUS or bedside CXR are critical in patients requiring close and repeated monitoring. Moreove. LUS and CXR reduce the radiation burden and the risk of infection compared with CT. PET/CT and MR. especially in ARDS patient. are not usually used for diagnostic or follow-up purposes.

# 2019 年冠状病毒病导致的急性呼吸衰竭患者的胸部成像。

综述目的：本综述旨在探索不同的影像学检查方法，如胸部 x 线摄影 (CXR)、计算机断层扫描 (CT)、超声、PET/CT 扫描和 MRI，以描述 COVID-19 ARDS 患者胸部评价的主要特征。

近期结果：本文包括系统性文献检索，证明了 COVID-19 中 ARDS 患者使用的不同胸部成像模式。文献证据表明，从传统 CXR 和 CT 至 LUS、MRI 和 PET/CT 的可能方法不同。

总结：在 COVID-19 患者中，CT 是研究胸部的敏感性和定义更高的技术。LUS 或床旁 CXR 对需要密切和重复监测的患者至关重要。此外，与 CT 相比，LUS 和 CXR 降低了辐射负荷和感染风险。PET/CT 和 MRI，尤其是 ARDS 患者，通常不用于诊断或随访目的。

期：1 ；页码：17-24； DOI：10.1097/MCC.0000000000000906

# Pathophysiology of coronavirus-19 disease acute lung injury.

Author: Luigi Camporot. John Croni. Mattia Busan. Luciano Gattinon. Federico Formenti

Abstract: Purpose of review: More than 230 million people have tested positive for severe acute respiratory syndrome-coronavirus-2 infection globally by September 2021. The infection affects primarily the function of the respiratory syste. where ~20% of infected individuals develop coronavirus-19 disease (COVID-19) pneumonia. This review provides an update on the pathophysiology of the COVID-19 acute lung injury.

Recent findings: In patients with COVID-19 pneumonia admitted to the intensive care uni. the PaO2/FiO2 ratio is typically <26.7 kPa (200 mmHg. whereas lung volume appears relatively unchanged. This hypoxaemia is likely determined by a heterogeneous mismatch of pulmonary ventilation and perfusio. mainly associated with immunothrombosi. endothelialitis and neovascularisation. During the diseas. lung weigh. elastance and dead space can increas. affecting respiratory driv. effort and dyspnoea. In some severe case. COVID-19 pneumonia may lead to irreversible pulmonary fibrosis.

Summary: This review summarises the fundamental pathophysiological features of COVID-19 in the context of the respiratory system. It provides an overview of the key clinical manifestations of COVID-19 pneumoni. including gas exchange impairmen. altered pulmonary mechanics and implications of abnormal chemical and mechanical stimuli. It also critically discusses the clinical implications for mechanical ventilation therapy.

# 冠状病毒 - 19 病急性肺损伤的病理生理学。

审查目的：截至 2021 年 9 月，全球已有超过 2.3 亿人检测出严重急性呼吸综合征 - 冠状病毒 - 2 感染阳性。感染主要影响呼吸系统功能，约 20% 的感染者发生冠状病毒 - 19 (COVID-19) 肺炎。这篇综述提供了 COVID-19 急性肺损伤病理生理学的更新。

近期结果：在入住重症监护室的 COVID-19 肺炎患者中，PaO2/FiO2 比值通常 <26.7 kPa (200 mmHg)，而肺容量似乎相对不变。这种低氧血症很可能是由肺通气和灌注的异质性不匹配决定的，主要与免疫血栓形成、内皮炎和新生血管形成相关。疾病期间，肺重量、弹性和死腔可能增加，影响呼吸驱动力、劳力和呼吸困难。在一些严重病例中，COVID-19 肺炎可能导致不可逆的肺纤维化。

总结：本综述总结了呼吸系统中 COVID-19 的基本病理生理学特征。它概述了 COVID-19 肺炎的关键临床表现，包括气体交换受损、肺力学改变和异常化学和机械刺激的影响。它还严格讨论了机械通气治疗的临床意义。

期：1 ；页码：9-16； DOI：10.1097/MCC.0000000000000911

# Phenotyping in acute respiratory distress syndrome: state of the art and clinical implications.

Author: Narges Alipana. Carolyn Calfee

Abstract: Purpose of review: Decades of research in acute respiratory distress syndrome (ARDS) have led to few interventions that impact clinical outcomes. The pandemic of patients with ARDS due to the novel SARS-CoV-2 infection has stressed the need for more effective therapies in ARDS. Phenotyping may enable successful trials and precision therapeutics in this patient population.

Recent findings: Clinical phenotypes that group patients by shared caus. time-course or radiographic presentation are of prognostic valu. but their use is limited by misclassification. Physiological phenotype. including the P/F rati. ventilatory ratio and dead space fractio. predict poor outcomes but can rapidly chang. making them unstable over time. Biologic phenotypes have prognostic value with composite clinical and biomarker sub-phenotypes additionally impacting treatment response but are yet to be prospectively validated.

Summary: Although much progress has been made in ARDS phenotypin. implementation of precision medicine practices will depend on conducting phenotype-aware trials using rapid point of care assays or machine learning algorithms. Omics studies will enhance our understanding of biologic determinants of clinical outcomes in ARDS sub-phenotypes. Whether biologic ARDS sub-phenotypes are specific to this syndrome or rather more broadly identify endotypes of critical illness remains to be determined.

# 急性呼吸窘迫综合征的表型：最新技术水平和临床意义。

综述目的：急性呼吸窘迫综合征 (ARDS) 的数十年研究几乎没有影响临床结局的干预措施。由于新型 SARS-CoV-2 感染引起的 ARDS 患者的流行，强调了 ARDS 需要更有效的疗法。表型分型可能使该患者人群的试验和精准治疗获得成功。

近期结果：根据共同原因、时程或放射学表现对患者进行分组的临床表型具有预后价值，但其使用受到错误分类的限制。生理表型（包括 P/F 比、通气比和死腔分数）可预测不良结局，但可快速变化，使其随时间推移变得不稳定。生物表型具有预后价值，复合临床和生物标志物亚表型还会影响治疗缓解，但尚未进行前瞻性验证。

总结：虽然 ARDS 表型分析已经取得了很大进展，但是精确医学实践的实施将取决于使用快速床旁检测或机器学习算法进行表型认知试验。群体研究将增进我们对 ARDS 亚表型临床结局生物学决定因素的理解。生物学 ARDS 亚表型是否是该综合征所特有的，或更广泛地确定危重病的内型仍有待确定。

期：1 ；页码：1-8； DOI：10.1097/MCC.0000000000000903

编辑

上次更新: 2022/08/11, 23:04:56

← 危重儿童常用镇静镇痛评估方法期刊题录 -- 2022 Critical Care Medicine→

期刊题录 -- 2022 Current Opinion In Critical Care

# 期刊题录 -- 2022 Current Opinion In Critical Care

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