Background. Identifying the causative pathogens of central nervous system infections (CNSIs) is crucial, but the low detection rate of traditional culture methods in cerebrospinal fluid (CSF) has made the pathogenic diagnosis of CNSIs a longstanding challenge. Patients with CNSIs after neurosurgery often overlap with inflammatory and bleeding. Metagenomic next-generation sequencing (mNGS) has shown some benefits in pathogen detection. This study aimed to investigate the diagnostic performance of mNGS in the etiological diagnosis of CNSIs in patients after neurosurgery. Methods. In this prospective observational study, we enrolled patients with suspected CNSIs after neurosurgical operations who were admitted to the intensive care unit of Beijing Tiantan Hospital. All enrolled patients' CSF was tested using mNGS and pathogen culture. According to comprehensive clinical diagnosis, the enrolled patients were divided into CNSIs group and non-CNSIs group to compare the diagnostic efficiency of mNGS and pathogen culture. Results. From December 2021 to March 2023, 139 patients were enrolled while 66 in CNSIs group and 73 in non-CNSIs. The mNGS exceeded culture in the variety and quantity of pathogens detected. The mNGS outperformed traditional pathogen culture in terms of positive percent agreement (63.63%), accuracy (82.01%), and negative predictive value (75.00%), with statistically significant differences (P < 0.05) for traditional pathogen culture. The mNGS also detected bacterial spectrum and antimicrobial resistance genes. Conclusions. Metagenomics has the potential to assist in the diagnosis of patients with CNSIs who have a negative culture.

This review summarizes the current research advances and guideline updates in neurocritical care. For the therapy of ischemic stroke, the extended treatment time window for thrombectomy and the emergence of novel thrombolytic agents and strategies have brought greater hope for patient recovery. Minimally invasive hematoma evacuation and goal-directed bundled management have shown clinical benefits in treating cerebral hemorrhage. In the treatment of aneurysmal subarachnoid hemorrhage (aSAH), early lumbar drainage can reduce the risk of infarction. Decompressive craniectomy for severe traumatic brain injury has also obtained high-quality evidence support. However, multimodal brain monitoring strategies for patients with traumatic brain injury need further optimization. For patients with cardiac arrest, extracorporeal cardiopulmonary resuscitation can reduce in-hospital mortality and improve long-term neurological prognosis. For neurocritical care patients, abundant high-quality studies have emerged in areas including multimodal neuromonitoring, hemodynamic management, airway management and respiratory therapy, and antiepileptic treatment. In 2023, the guidelines for aSAH have been updated for the first time in the past decade, aiming to provide evidence-based practice recommendations for clinical care. Chinese expert consensuses have also been formulated to guide analgesia and sedation for neurocritical care patients and developed a set of medical quality indicators on neurocritical care, which will enhance standardization and homogenization improvement in neurocritical care quality.

Sedation and analgesia therapy are essential in neurocritical care, but there are ongoing controversies surrounding assessment, administration, and withdrawal. With advances in neurocritical care medicine, updated evidence-based medicine, considering the variability in knowledge and practice, the National Center for Healthcare Quality Management in Neurological Diseases and the Chinese Society of Critical Care Medicine organized experts in neurocritical care to form a working group [Supplementary File 1, https://links.lww.com/CM9/B958] to update the "Expert Consensus on Sedation and Analgesia for Patients with Severe Brain Injury (2013)".[1] This update aimed to review and summarize the literature published since 2013 across different aspects of sedation and analgesia in neurocritical care patients and has been registered on http://www.guidelines-registry.org (No. PREPARE-2023CN332). The scope of this consensus is limited to adult patients admitted to neurocritical care units because of primary and/or secondary brain injuries. Applying the modified Delphi method to collect, feedback and discuss expert opinions through three rounds of Delphi questionnaires and one round of face-to-face meeting, this update addressed 5 domains with 18 questions and formulated 31 recommendations. This consensus is intended for use by healthcare professionals involved in caring for neurocritical care patients.[2] Following each recommendation, we present the percentage level of agreement followed by the rate of participants voting in favor to the total number of participants casting their vote. Goal of Analgesia and Sedation for Neurocritical Care Patients Question 1: What is the goal of analgesia and sedation for neurocritical care patients? Recommendation 1: Analgesia and sedation are essential components of neurocritical care patient management. The general goals of analgesia and sedation for neurocritical care patients are to relieve/eliminate pain, anxiety and agitation, improve sleep, induce amnesia, reduce stress, decrease oxygen consumption, increase comfort, and correct patient-ventilator asynchrony (100%; 36/36). Recommendation 2: The neuro-specific goals of analgesia and sedation for neurocritical care patients, especially for patients at risk of secondary brain injuries such as intracranial hypertension, should consider brain protection, including controlling intracranial pressure, maintaining optimal cerebral perfusion, inhibiting the sympathetic nervous system, controlling seizures, and preventing/alleviating secondary brain injury (100%; 36/36). Question 2: Should analgesia and sedation be administered for neurocritical care patients with intracranial hypertension? Recommendation 3: Analgesia and sedation are fundamental therapy for neurocritical care patients with intracranial hypertension (100%; 36/36). Question 3: Should analgesia and sedation be administered during targeted temperature management (TTM) for neurocritical care patients? Recommendation 4: Analgesia and sedation can be administered for neurocritical care patients undergoing TTM (100%; 36/36). Monitoring of Neurocritical Care Patients During Analgesic and Sedative Therapy Question 4: Should pain assessment be performed for neurocritical care patients? Question 5: How should pain assessment tools be chosen for neurocritical care patients? Recommendation 5: Pain assessment should be performed for neurocritical care patients (100%; 36/36). Recommendation 6: Appropriate pain assessment tools should be chosen based on the level of consciousness and verbal ability of neurocritical care patients (97.2%; 35/36). Recommendation 7: For neurocritical care patients who can self-report pain, pain assessment tools include Numerical Rating Scale (NRS), Visual Analogue Scale (VAS), Changhai Pain Rating Scale. For patients who can not accurately self-report pain, options include Faces Pain Thermometer (FPT), Behavioral Pain Scale (BPS), Critical-care Pain Observation Tool (CPOT), the Revised Adult Nonverbal Pain Scale (NVPS-R), Pupil Light Reflex (PLR), etc, (97.2%; 35/36). Recommendation 8: Vital sign changes alone are not recommended as the sole method for pain assessment but can be used as an adjunct to the detection of underlying pain (100%; 36/36). Question 6: Should sedation assessment be performed for neurocritical care patients? Question 7: How should sedation assessment methods be chosen for neurocritical care patients? Recommendation 9: Sedation assessment should be performed for neurocritical care patients. (100%; 36/36). Recommendation 10: For neurocritical care patients, available subjective sedation assessment tools include Sedation-Agitation Scale (SAS), Richmond Agitation-Sedation Scale (RASS), etc., but their utility is limited for patients with persistent coma (100%; 36/36). Recommendation 11: Based on the characteristics of neurocritical care patients, objective assessment tools like quantitative electroencephalography (qEEG), bispectral index (BIS), etc., can be used to evaluate the level of sedation (97.2%; 35/36). Question 8: How should the depth of sedation be chosen for neurocritical care patients? Recommendation 12: For neurocritical care patients with suspected organ dysfunction like intracranial hypertension, light sedation (RASS –2 to –1, SAS 3 to 4) should be avoided. When organ function tends to be stable, transitioning from deep sedation to light sedation/no sedation can be considered (97.2%; 35/36). Question 9: Should Neurologic Wake-Up Test (NWT) be performed for neurocritical care patients? Recommendation 13: Consideration of using of NWT to assess neurological function in neurocritical care patients is warranted, but the timing of NWT should be balanced against risks and benefits (100%; 36/36). Recommendation 14: In neurocritical care patients with suspected severe conditions like intracranial hypertension, routine NWT should be avoided (100%; 36/36). Question 10: Should neurological examination be performed during analgesic and sedative therapy for neurocritical care patients? Recommendation 15: Neurological examination should be performed during analgesic and sedative therapy for neurocritical care patients. Examinations should include level of consciousness, pupil reactions, neurological examination (cranial nerves, motor, sensory, respiratory pattern, brainstem reflexes, etc.), laboratory, and imaging (100%; 36/36). Question 11: Should one or more multimodal neuromonitoring techniques be used for objective monitoring during analgesic and sedative therapy for neurocritical care patients? Recommendation 16: Multimodal monitoring can dynamically evaluate the safety and efficacy of analgesic and sedative therapy from different dimensions (100%; 36/36). Question 12: Should delirium assessment be performed for neurocritical care patients? Question 13: How should delirium assessment tools be chosen for neurocritical care patients? Recommendation 17: Delirium assessment should be performed for neurocritical care patients and should not be overlooked even with existing/potential neurological deficits (100%; 36/36). Recommendation 18: The confusion assessment method for the intensive care unit (CAM-ICU) or intensive care delirium screening checklist (ICDSC) are commonly used tools for delirium assessment in neurocritical care patients. Quick screening tools such as 4A's test (4AT) can help identify delirium early (97.2%; 35/36). Recommendation 19: For patients with severe neurological conditions such as impaired consciousness and aphasia, appropriate assessment tools should be chosen, and the results of the assessment should be interpreted cautiously. For patients with aphasia, ICDSC may be more valuable than CAM-ICU (97.2%; 35/36). Recommendation 20: Risk factors for delirium in neurocritical care patients include age, mechanical ventilation, sepsis, aphasia, sleep deprivation, physical restraints, and frontal lobe lesions (100%; 36/36). Analgesic and Sedative Medications Selection Question 14: How should analgesic and sedative agents be selected for neurocritical care patients? Recommendation 21: There is currently no superior strategy for the selection of analgesic and sedative agents in neurocritical care patients. Opioids, midazolam, and propofol were the most commonly prescribed agents (100%; 36/36). Recommendation 22: Selection should be based on patient characteristics, treatment needs, and pharmacological properties of the agents. Caution is needed for the adverse effects of analgesic/sedative agents (especially opioids), such as respiratory depression, hypotension, effects on consciousness, tolerance, withdrawal, etc., particularly in special populations (hemodynamic instability, hepatic/renal insufficiency, elderly, and obesity) (100%; 36/36). Recommendation 23: Short-acting or ultra-short-acting agents may be more appropriate when accurate and rapid assessment of neurological function is required in neurocritical care patients (100%; 36/36). Recommendation 24: The use of ketamine should be cautious in neurocritical care patients (94.4%; 34/36). Recommendation 25: The efficacy of dexmedetomidine in the prevention and treatment of delirium in neurocritical care patients needs to be further confirmed (94.4%; 34/36). Role of Analgesic and Sedative Therapy in Refractory Intracranial Hypertension Question 15: Should analgesic and sedative therapy be increased for neurocritical care patients with refractory intracranial hypertension? Recommendation 26: Analgesic and sedative therapy should be increased for neurocritical care patients with refractory intracranial hypertension (97.2%; 35/36). Recommendation 27: Adverse effects like propofol infusion syndrome (PRIS) should be monitored with high-dose sedative therapy (100%; 36/36). Question 16: Is barbiturate coma treatment recommended for the treatment of refractory intracranial hypertension? Recommendation 28: Barbiturate can be titrated to intracranial pressure control for refractory intracranial hypertension unresponsive to other conservative management (91.7%; 33/36). Application of Analgesic and Sedative Therapy in TTM Question 17: How should analgesic and sedative agents be selected for neurocritical care patients undergoing TTM? Question 18: Is the adjunctive use of neuromuscular blockade recommended for TTM in neurocritical care patients? Recommendation 29: The selection of analgesic and sedative agents for TTM should be based on patient characteristics, treatment needs, and pharmacological properties of the agents. Hypothermia can result in slower drug metabolism and elimination and prolonged action duration, so that short-acting agents may be more appropriate (97.2%; 35/36). Recommendation 30: There is currently no evidence on the optimal analgesic and sedative agents for neurocritical care patients undergoing TTM. Fentanyl, midazolam, and propofol were the most commonly prescribed agents (100%; 36/36). Recommendation 31: The routine use of neuromuscular blockade should be avoided for TTM in neurocritical care patients (100%; 36/36). Funding The work was supported by grants from the Beijing Municipal Science and Technology Commission (No. Z201100005520050), and Beijing Municipal Health Commission (No. BHTPP2022026). Conflicts of interest None. Acknowledgments This article is based on the mandarin version of consensus first reported in the Journal of Chinese Critical Care Medicine 2023;35: 897–918.

BackgroundAcute respiratory distress syndrome (ARDS) is a severe condition characterized by lung stiffness and compromised gas exchange, often requiring mechanical ventilation for treatment. In addition to its clinical significance, understanding the publication trends and research patterns in respiratory mechanics related to ARDS can provide insights into the evolution of this field from a bibliometric perspective, aiding in strategic planning and resource allocation for future research endeavors.ObjectiveThis study aimed to explore the trends and identify the hotspots in respiratory mechanics research related to ARDS.MethodsAll relevant studies on respiratory mechanics of ARDS published between 1985 and 2023 were retrieved from the Web of Science Core Collection (WoSCC), and the retrieval strategy was topic search “TS = respiratory mechanics OR lung mechanics AND TS = ARDS OR acute respiratory distress syndrome.” Annual trends, citation patterns, and contributions from countries, institutions, authors, and journals were analyzed using Bibliometrix Biblioshiny. Networks and overlay of authors, institutions, countries, journals, co-citations, and keywords were analyzed and visualized using VOSviewer.ResultsOur analysis included 1,248 articles published between 1985 and 2023, revealing fluctuations in publication output over time. The United States emerged as the leading contributor, with Critical Care Medicine being the most prominent journal. Key research themes included mechanical ventilation, acute lung injury, and protective ventilation strategies. International collaboration was evident, facilitating knowledge exchange and interdisciplinary cooperation.ConclusionOur study sheds light on the evolving landscape of respiratory mechanics research in ARDS. International collaboration is pivotal in advancing the field, while researchers increasingly focus on personalized approaches to address the complexities of ARDS respiratory mechanics.

ABSTRACTCentral nervous system infections (CNSIs) are common complications after neurosurgery with a poor prognosis. The traditional microbiological culture methodology has a low detection rate and time consuming. Metagenomic next-generation sequencing (mNGS) has demonstrated the advantages of being faster, more accurate, and more comprehensive in clinical microbiology. Previous studies had suggested that mNGS had a high sensitivity in the diagnosis of CNSIs. Whether the application of mNGS has health economic value in clinical applications remains to be studied. We designed a prospective, single-center, superiority randomized controlled trial to compare the cost-effectiveness of mNGS with traditional methods for diagnosing CNSIs using a decision tree model. A total of 204 patients will be enrolled and randomly assigned to either the mNGS group or the traditional method group. The two groups of patients entered different decision points according to different clinical manifestations and examination results. They will be then given treatment decisions by a panel of specialists at the corresponding decision point. The primary outcome is the incremental cost-effectiveness ratio, which is the increased cost for every 1% increase in recovery rate. The secondary outcomes are a comparison of time cost, detection cost, and costs associated with antibiotics treatment between the two groups.IMPORTANCEDiagnosing and treating postoperative central nervous system infections (PCNSIs) remains challenging due to the low detection rate and time-consuming nature of traditional methods for identifying microorganisms in cerebrospinal fluid. Metagenomic next-generation sequencing (mNGS) technology provides a rapid and comprehensive understanding of microbial composition in PCNSIs by swiftly sequencing and analyzing the microbial genome. The current study aimed to assess the economic impact of using mNGS versus traditional bacterial culture-directed PCNSIs diagnosis and therapy in post-neurosurgical patients from Beijing Tiantan Hospital. mNGS is a relatively expensive test item, and whether it has the corresponding health-economic significance in the clinical application of diagnosing intracranial infection has not been studied clearly. Therefore, the investigators hope to explore the clinical application value of mNGS detection in PCNSIs after neurosurgery.

Analgesia and sedation are crucial for critically ill patients. In recent years, a comprehensive strategy featuring prioritized analgesia, light sedation, delirium screening and prevention, early mobility and sleep improvement has been formed. However, a concise and easy-to-operate flow chart still needs to be improved. We have developed a protocolized process for pain and agitation management for critically ill patients to provide a hands-on tool in clinical practice.

To further standardize the sedation and analgesia treatment for neurocritical care patients, the National Center for Healthcare Quality Management in Neurological Diseases and Chinese Society of Critical Care Medicine organized national experts in this fields to form Working group of the Expert consensus on sedation and analgesia for neurocritical care patients in order to update the Expert consensus on sedation and analgesia for patients with severe brain injury (2013) based on evidence-based medicine. This update aims to provide scientific guidance for the clinical diagnosis and treatment of neurocritical care patients. The working group followed the definition of clinical practice guidelines by the Institution of Medicine (IOM) and the World Health Organization guidelines development handbook and Guidelines for the formulation/revision of clinical guidelines in China (2022) to register and draft the Expert consensus on sedation and analgesia for neurocritical care patients. The working group will strictly adhere to the consensus development process to formulate and publish the Expert consensus on sedation and analgesia for neurocritical care patients (2023). This protocol primarily introduces the development methodology and process of the Expert consensus on sedation and analgesia for neurocritical care patients (2023), including the purpose of the update, the target population, the composition of the consensus development working group, the presentation and collection of clinical questions, evidence evaluation and summarization, and the generation of recommended opinions. This will make the consensus development process more standardized and transparent.