Critical Pulse

‌Review the Latest Research in Critical Care

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Remote Monitoring Does Not Appear to Reduce Hospital Readmissions in Older Adults With Sepsis or Lower Respiratory Infection

An RCT published in JAMA Network evaluated the effectiveness of remote monitoring in reducing readmissions following hospitalizations for serious infections overall and across prespecified subgroups. The study included 1286 patients who were randomized to usual care or remote patient monitoring (RPM) with low- or high-intensity questionnaires and standard or enhanced clinical response team combinations: RPM-low standard response, RPM-high standard response, RPM-low enhanced response, and RPM-high enhanced response. The median home days were similar across all study arms. Compared with usual care, the cumulative odds ratios (CORs) were 0.96 (credible interval [CrI], 0.70-1.32) for RPM-low standard response, 0.86 (95% CrI, 0.60-1.23) for RPM-high standard response, 1.01 (95% CrI, 0.76-1.33) for RPM-low enhanced response, and 0.96 (95% CrI, 0.69-1.36) for RPM-high enhanced response, and superiority probability was less than 55% for all comparisons. Among patients 65 years and older, standard and enhanced response arms had fewer home days compared with usual care (COR, 0.56 [95% CrI, 0.36-0.85] and 0.67 [95% CrI, 0.45-0.98], respectively). These findings support reevaluating and tailoring remote monitoring after acute care for sepsis and lower respiratory tract infection to support further alignment with patients’ needs and desire for personalized monitoring.

Higher Dose Compared to Lower Dose of Corticosteroids Does Not Appear to Reduce Mortality in Hospitalized Patients With Community-Acquired Pneumonia

A systematic review and network meta-analysis published in Critical Care evaluated the efficacy of higher-dose versus lower-dose corticosteroids to treat patients with community-acquired pneumonia (CAP). Thirty-two RCTs that included 9746 participants were included. Compared with placebo or usual care, higher-dose corticosteroids were associated with lower short-term mortality (RR = 0.83; 95% CI, 0.74-0.92), as were lower-dose corticosteroids (RR = 0.84; 95% CI, 0.75-0.95). The indirect comparison showed no clear difference between higher- and lower-dose regimens (RR = 0.98; 95% CI, 0.83-1.16). In patients with severe CAP, the corresponding indirect estimate was RR = 1.01 (95% CI, 0.77-1.33). Future research is needed to evaluate whether selected inflammatory phenotypes benefit from higher-dose corticosteroids.

Lung Ultrasound Score Can Help Predict Surfactant Requirement in Preterm Neonates With ARDS

A systematic review and meta-analysis published in Scientific Reports evaluated the diagnostic accuracy of lung ultrasound (LUS) score in predicting surfactant requirement in preterm neonates with ARDS. Eighteen studies including 997 neonates were included. The pooled sensitivity and specificity of overall studies were 0.85 (95% CI, 0.83-0.87) and 0.80 (95% CI, 0.77-0.82). A diagnostic odds ratio was 32.12 (95% CI, 18.99-54.33), indicating strong overall discriminatory ability. The area under sROC curve was 0.682. Subgroup analysis ≤6 showed higher sensitivity but lower specificity, which is more useful for early screening. A cutoff between 7 and 8 had balanced diagnostic value, and a cutoff ≥9 had higher specificity which showed stronger confirmation for surfactant requirement. LUS can support timely clinical decision-making and early surfactant administration in the NICU when used with clinical assessment.

Early Initiation of VA-ECMO Appears to Reduce Short-Term Mortality in Patients With Cardiogenic Shock

A systematic review and meta-analysis published in the Journal of Intensive Medicine evaluated whether early initiation of VA-ECMO in patients with cardiogenic shock is associated with improved outcomes compared to delayed initiation. Eight observational studies involving 10,451 patients were included. Early VA-ECMO initiation was associated with reduced short-term mortality compared to delayed initiation (OR = 0.74; 95% CI, 0.58-0.96). No significant differences were found between the two groups for neurological (OR = 0.67; 95% CI, 0.34-1.33), bleeding (OR = 0.83; 95% CI, 0.56-1.23), or ischemic (OR = 0.87; 95% CI, 0.32-2.41) complications and long-term mortality (OR = 0.63; 95% CI, 0.39-1.02). Sensitivity analyses indicated consistent results: adjusted estimates (OR = 0.69; 95% CI, 0.53-0.89), pre- to revascularization VA-ECMO initiation (OR = 0.40; 95% CI, 0.23-0.68), and initiation approximately 2 hours after shock diagnosis (OR = 0.69; 95% CI, 0.49-0.97). Future RCTs are needed to determine the optimal timing and patient selection for VA-ECMO initiation.

ML Models Show Promising Accuracy for Predicting Pediatric Cardiac Surgery‒Associated AKI

A systematic review and meta-analysis published in Frontiers in Cardiovascular Medicine investigated the diagnostic accuracy of ML models for predicting pediatric cardiac surgery‒ associated AKI (CSA-AKI). A meta-analysis of seven studies yielded a pooled SROC AUC of 0.91 (95% CI, 0.88-0.93), driven predominantly by internally validated models (AUC, 0.93; sensitivity, 0.84; specificity, 0.95). Externally validated models showed substantially lower performance (sensitivity, 0.70; specificity, 0.80), representing the more clinically relevant benchmark. A sensitivity analysis using median-performing models confirmed directional consistency (AUC, 0.85; sensitivity, 0.75; specificity, 0.91). Substantial heterogeneity and limited external validation warrant cautious interpretation and further multicenter validation before clinical use.

Low Tidal Volume Combined With Low Airway Pressure May Offer a Protective Ventilation Strategy for Non-ARDS Patients

A systematic review and meta-analysis in Biomedical Reports aimed to compare the effects of low with high tidal volume (Vt) ventilation in non-ARDS patients. Eighteen studies comprising 3042 patients were included. No significant difference in short-term mortality was observed between low and high Vt ventilation (OR = 0.88; 95% CI, 0.71-1.09). However, subgroup analysis by maximum airway pressure (Pmax) showed that low Vt with low Pmax significantly reduced short-term mortality compared with low Vt with Pmax (OR = 0.50; 95% CI, 0.34-0.75). Low Vt also decreased days of ventilation (MD = ‒1.00 days; 95% CI, ‒1.76 to ‒0.24), pulmonary complications (OR = 0.40; 95% CI, 0.30-0.54), and hospital stay (MD = ‒1.49 days; 95% CI, ‒2.54 to ‒0.44). Trial sequential analysis indicated conclusive evidence, suggesting that further trials are unlikely to change the conclusion.

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