OBJECTIVES:To describe the utilization, feasibility, and operator-reported diagnostic and management impact of transesophageal lung ultrasound (TELUS) integrated into resuscitative transesophageal echocardiography (TEE) for the assessment of mechanically ventilated adults with shock. DESIGN:Multicenter observational cohort study using prospectively collected data. SETTING:Twenty-three hospitals from the Resuscitative Transesophageal Echocardiography Collaborative Registry (rTEECoRe) network. PATIENTS:From 1213 registry TEE examinations, 379 met the inclusion criteria for shock evaluation or hemodynamic monitoring in mechanically ventilated adults; 96 (25.3%) of these included TELUS. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:TELUS integration was associated with significantly higher operator-reported identification of shock etiology compared with resuscitative TEE alone (86.5% vs. 75.3%; odds ratio [OR], 1.95; 95% CI, 1.02-3.72; p = 0.04). Although overall clinical management changes were more frequently reported in the TELUS group, this difference did not reach statistical significance (78.1% vs. 71.7%; OR, 1.40; 95% CI, 0.82-2.41; p = 0.22). TELUS examinations were associated with longer procedure duration (median 21.5 vs.19.0 min; p = 0.01) and were predominantly performed by intensivists. Pulmonary findings, including B-lines, pleural effusions, consolidations, and A-line patterns, varied in frequency and were occasionally associated with specific respiratory or antimicrobial interventions. Procedure-related complications were rare and similar between groups. CONCLUSIONS:In this multicenter cohort of mechanically ventilated adults with shock, adding TELUS to resuscitative TEE was associated with a higher rate of operator-reported identification of shock etiology and was feasible with minimal additional procedure time. Prospective studies with standardized TELUS acquisition and interpretation, independent adjudication, and evaluation of patient-centered outcomes are needed to define clinical scenarios of incremental value.
OBJECTIVES:Sepsis is a leading cause of morbidity and mortality for critically ill children, yet the pattern of healthcare use before admission for sepsis remains unknown. We measured the proportion and characteristics of healthcare encounters within 7 days before sepsis hospitalizations. DESIGN:Using the Merative MarketScan administrative claims database, we conducted a retrospective observational cohort study to quantify pre-admission healthcare encounters among children hospitalized with sepsis. SETTING:The Merative MarketScan database includes inpatient, outpatient, and emergency medical claims from employer-based insurance plans and Medicaid data from approximately 7 million healthcare consumers across multiple states. PATIENTS:Included patients were 0-18 years old and hospitalized with sepsis between January 1, 2016, and December 31, 2022. Children were required to have 30 days of continuous insurance enrollment before admission. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:Our primary outcome was the occurrence of any healthcare encounter in the 7 days before sepsis hospitalization, including outpatient, emergency department, or inpatient visits. Of those encounters, we identified the proportion that were related to infection. We compared hospitalization characteristics, including mechanical ventilation, ICU use, and length of stay, among those with vs. without pre-sepsis healthcare utilization. We identified 6928 pediatric sepsis hospitalizations, of whom 64.3% (4452/6928) had a complex chronic condition with a median age of 10 years (interquartile range, 3-15 yr). Overall, 53.5% (3707/928) of sepsis hospitalizations had a healthcare encounter within 7 days of admission, including 33.7% (2338/6928) with an outpatient visit, 28.2% (1956/6928) with an emergency department visit, and 6.2% (431/6928) with an inpatient hospitalization. Among sepsis hospitalizations with any pre-admission encounter, 38.9% (1445/3707) had an infection-related diagnosis documented at the encounter. There was no difference in mechanical ventilation, ICU use, or length of stay between those with vs. without pre-sepsis healthcare encounters. CONCLUSIONS:Over half of children hospitalized with sepsis were evaluated in the outpatient or emergency department setting in the week preceding admission, with one in five evaluated for infection. Further understanding of these pre-admission encounters may allow for earlier sepsis identification and possibly intervention in the prehospital setting.
OBJECTIVES:To evaluate long-term all-cause mortality and functional outcomes among critically ill adults treated with extracorporeal membrane oxygenation (ECMO), including differences by ECMO modality and clinical indication. DATA SOURCES:Ovid MEDLINE, Embase, Emcare, Central Register of Controlled Trials, and Scopus were searched to March 2025. STUDY SELECTION:Randomized controlled trials and observational studies reporting mortality or functional outcomes at or beyond 6 months in adults receiving ECMO were eligible for inclusion. DATA EXTRACTION:A systematic review and meta-analysis were conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines and prospectively registered with PROSPERO (CRD420251002639). Two reviewers independently extracted data. Mortality was pooled using random-effects meta-analysis with 95% CIs. Prespecified subgroup analyses examined ECMO modality and clinical indication. Sensitivity analyses assessed the impact of missing outcome data. Functional outcomes were narratively synthesized due to heterogeneity. DATA SYNTHESIS:A total of 163 studies including 78,053 adults met inclusion criteria, with 59,454 adults in 156 of 163 studies (95.7%) contributing to mortality meta-analyses. At 1 year, pooled mortality was 37.2% (95% CI, 30.0-45.1%) in 13 of 33 venovenous ECMO studies (39.4%), 55.2% (95% CI, 50.2-60.1%) in 42 of 55 venoarterial ECMO studies (76.4%), and 74.4% (95% CI, 71.4-77.2%) in 14 of 24 (58.3%) extracorporeal cardiopulmonary resuscitation (ECPR) studies. Functional outcomes were reported in 38 of 163 studies (23.3%) in 7,876 survivors and were assessed using various instruments, most commonly the Cerebral Performance Category in 20 of 38 studies (52.6%), the World Health Organization Disability Assessment Schedule 2.0 in five of 38 studies (13.2%), and the modified Rankin Scale in five of 38 studies (13.2%). CONCLUSIONS:Long-term mortality following ECMO differed substantially by ECMO modality, ranging from 37.2% among adults receiving venovenous ECMO to 74.4% among adults receiving ECPR. Functional outcomes were inconsistently reported, limiting the understanding of functional recovery among survivors. Standardized reporting and benchmarking are required to better inform long-term prognosis, patient selection, and factors that may improve functional recovery after ECMO.
OBJECTIVES:Research examining informed consent in critical care studies is limited. The objective of this study was to describe the patterns and predictors of consent. DESIGN:Research coordinators prospectively documented each consent encounter including consent model (a priori or deferred, also known as consent to continue), who requested consent (research coordinator, site investigator, and ICU physician), who provided or declined consent (patient, substitute decision-maker [SDM], and other), the method to obtain consent (in-person or via telephone), and reasons for consent decline, if applicable. Research coordinators retrospectively reported center characteristics. Using multilevel logistic regression, we evaluated the association of consent provision with characteristics of the consent encounter and participating center. SETTING:International randomized trial of stress ulcer prophylaxis for invasively ventilated patients. INTERVENTION:None. MEASUREMENTS AND MAIN RESULTS:Among 5024 patients or SDMs approached for consent, the consent rate was 85.0% (ranging from 27.3% to 100%). In 2638 patients (52.5%), an a priori approach was used, and of these, 696 patients (26.4%) declined. The remaining 2386 participants (47.5%) were enrolled by deferred consent, of whom 58 participants (2.4%) ultimately declined. Among first consent encounters, 80.2% were with SDMs, 19.6% with patients, and 0.2% with others. Higher consent rates were independently associated with the deferred consent model (odds ratio [OR], 16.56; 95% CI, 11.50-23.84), consent encounters involving patients (OR, 2.67; 95% CI, 1.63-4.37), and consent encounters during the COVID-19 pandemic (OR, 2.01; 95% CI, 1.30-3.11) or postpandemic period (OR, 2.26; 95% CI, 1.34-3.80) compared with prepandemic. Consent rates were not associated with center characteristics including ICU size, ICU research experience, or research coordinator experience. CONCLUSIONS:Deferred consent was used as often as a priori consent in this trial. The informed consent rate was associated with the deferred model, consent from patients, and consent encounters during or after the pandemic.
OBJECTIVES:To investigate whether gender disparity in authorship of critical care scientific publications is greater in studies originating from low- and middle-income countries (L/MICs) compared with those from high-income countries (HICs). DESIGN:Cross-sectional bibliometric analysis. SETTING:Original research publications, including observational studies and randomized controlled trials, published from 2018 to 2022 in the ten critical care journals with the highest 2022 impact factors as reported by Clarivate Analytics Journal Citation Reports. PATIENTS:A total of 4,982 publications, 4,479 from HICs, and 503 from L/MICs, comprising 50,357 authors. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:We evaluated the proportion of women authors overall, and in first and senior positions; proportions of coauthors; differences by country income classification; temporal trends; and subgroup analyses stratified by funding type. Women accounted for 31.3% of all authors, 35.4% of first authors, and 21.4% of senior authors. Women's representation was higher in L/MICs than in HICs (38.2% vs. 30.6%; p < 0.01). The proportion of women in first (40.7% vs. 34.7%; p < 0.01) and senior (27.6% vs. 20.7%; p < 0.01) positions was also higher in publications from L/MICs. Coauthorships (i.e., the dyad of first and senior authors) involving at least one woman accounted for less than 30% across all publications. There were temporal increases in overall and senior woman authorship in HICs (p < 0.01 for both) and in overall authorship in L/MICs (p = 0.02). Women authors were more frequently represented among funded publications from L/MICs. CONCLUSIONS:Among high-impact critical care journals, substantial gender disparities persisted in authorship of publications. Women are better represented in publications from L/MICs, and there was an increase in women's authorship over time in both HICs and L/MICs from 2018 to 2022.
