BACKGROUND AND AIMS:Persistent Inflammation, Immunosuppression, and Catabolism Syndrome (PIICS) was introduced as a clinical endotype of chronic critical illness and is frequently observed in patients with sepsis. Although nutritional therapy may affect immune function and disease progression, the relationship between malnutrition, nutritional delivery, and PIICS remains unclear. We herein investigated the incidence and outcomes of PIICS and examined its relationship with acute-phase nutritional therapy and Global Leadership Initiative on Malnutrition (GLIM) malnutrition in intensive care unit (ICU) patients with sepsis. METHODS:This was a secondary analysis of the multicenter prospective ILOSS study including adult (≥18 years) ICU patients with sepsis admitted between 2020 and 2021. PIICS was defined as a hospital stay ≥14 days and at least two of the following on day 14: lymphocyte count <800/μL, C-reactive protein >2.0 mg/dL, and albumin <3.0 g/dL. Malnutrition was defined using GLIM criteria. The primary outcome was the composite of in-hospital mortality or severe functional dependence, defined as Barthel index <60 at hospital discharge. A multivariable logistic regression analysis identified risk factors for PIICS, and energy and protein intakes on days 1-14 were compared between the PIICS and non-PIICS groups. RESULTS:Among 250 patients, 127 (50.8%) developed PIICS. The PIICS group had higher SOFA scores on ICU admission and the higher use of mechanical ventilation and renal replacement therapy during the ICU stay. GLIM malnutrition was more prevalent in the PIICS group. The primary outcome was more frequent in patients with PIICS at discharge (56.7% vs. 32.8%) and at 12 months (55.7% vs. 31.4%). GLIM malnutrition was independently associated with PIICS (OR 1.80, 95% CI 1.02-3.18; p = 0.04). Among patients without GLIM malnutrition at admission, energy and protein intakes on days 8-14 were lower in patients who subsequently developed PIICS. CONCLUSION:Approximately 50% of ICU patients with sepsis developed PIICS. Patients with PIICS had higher mortality and worse physical function and quality of life after discharge, although these differences attenuated over time. Pre-existing GLIM malnutrition seemed to be associated with an increased risk of developing PIICS. A causal relationship between nutritional delivery and PIICS development in patients with/without malnutrition requires further investigation.

Background Oral endotracheal intubation causes significant discomfort, and although opioid analgesia is recommended, it is associated with risks including increased mortality and delirium. Topical anesthesia around the endotracheal tube cuff reduces intubation-related discomfort in surgical patients, but optimal methods for critically ill patients remain unclear. Lidocaine administration via the subglottic secretion drainage (SSD) port may provide a novel, minimally invasive approach to topical anesthesia. Research Question Does lidocaine administration via the SSD port, combined with protocolized fentanyl infusion, reduce pain compared with protocolized fentanyl infusion alone in orally intubated critically ill patients? Study Design and Methods This phase 2, single-center, open-label, three-arm, cluster-crossover randomized controlled trial is being conducted at Tokyo Medical University Hospital, Japan. Patients aged 18–85 years with oral endotracheal intubation and Critical-Care Pain Observation Tool (CPOT) scores ≥2 will be enrolled from the intensive care unit (ICU), cardiac care unit, or emergency ICU. Participants will be allocated to Group A (2% lidocaine 2 mL via SSD port every 6 hours), Group B (4% lidocaine 4 mL via SSD port every 6 hours), or Group C (control), all receiving protocolized fentanyl infusion. The primary outcome is the CPOT score 30 minutes after the first intervention. Secondary outcomes include subsequent CPOT scores, analgesic doses, delirium incidence, and ventilator-free days. Safety outcomes include ventilator-associated pneumonia, blood lidocaine concentrations, and lidocaine toxicity. A sample size of 108 patients is planned with intention-to-treat analysis. Results Patient recruitment began on November 1, 2025, and is expected to be completed by July 31, 2026. Interpretation This trial will provide data on the efficacy and safety of lidocaine administration via the SSD port for pain management in critically ill intubated patients. Clinical Trial Registration Japan Registry of Clinical Trials, no. jRCTs052250085; Registered date: August 8, 2025; URL: https://jrct.mhlw.go.jp/

BACKGROUND:International statements suggest using the Global Leadership Initiative on Malnutrition (GLIM) criteria in intensive care units (ICUs); however, the economic impact of GLIM-defined malnutrition in sepsis remains unclear. This study investigated the association between GLIM-defined malnutrition and in-hospital costs in sepsis. METHODS:We conducted a sub-analysis of the prospective cohort study, Investing Long-term Outcomes of Sepsis or Septic shock, among medically managed critically ill patients with sepsis in 15 Japanese ICUs. Associations between GLIM-defined malnutrition and cost categories (low, moderate, and high) were assessed using multinomial logistic regression (reference: low-cost group), adjusted for age, sex, Charlson Comorbidity Index, and Sequential Organ Failure Assessment score. Individual GLIM components were also examined. Total in-hospital costs and secondary outcomes were compared between malnutrition and non-malnutrition groups using inverse probability of treatment weighting. RESULTS:Among 259 patients, 111 had GLIM-defined malnutrition. GLIM-defined malnutrition was associated with both the moderate-cost (adjusted odds ratio [AOR]: 2.03, 95% confidence interval [CI]: 1.05-3.89) and high-cost classifications (AOR: 2.27, 95% CI: 1.20-4.29). Among GLIM components, reduced muscle mass (AOR: 1.95, 95% CI: 1.04-3.68) and reduced food intake (AOR: 2.61, 95% CI: 1.39-4.92) were associated with the high-cost classification. After weighting, the malnutrition group had significantly higher median in-hospital costs (24,959 vs. 18,651 USD), longer hospital stays, and longer ICU stays than the non-malnutrition group. CONCLUSIONS:GLIM-defined malnutrition-particularly reduced muscle mass and reduced food intake-was associated with higher in-hospital costs in sepsis and may be a potential indicator of high-cost hospitalization.

Background Sepsis mimics can present with the same shock, fever, and organ dysfunction as sepsis, creating diagnostic uncertainty, delays in disease-specific therapy, and unnecessary antibiotics. How intensivists navigate these syndromes at the bedside is not well described. Methods A qualitative study design was employed. Semi-structured interviews exploring experiences with sepsis mimics were conducted with seven physicians (intensivists, emergency physicians, or general internists) with substantial ICU experience working in adult general ICUs in Japan. Data were collected online from October to December 2023. Data were analyzed using Reflexive Thematic Analysis (Braun & Clarke). Results Analysis generated four themes. (1) Spectrum: Sepsis mimics were relatively common and spanned hematologic malignancy, autoimmune/inflammatory disease, endocrine/metabolic crises, drug/toxic states, and other non-infectious SIRS-like conditions. Their diagnostic difficulty was heterogeneous, with some mimics usually recognized early and others repeatedly diagnosed only late or post-mortem. (2) Diagnostic challenges: These centered on phenotypic overlap with sepsis, unavailable or fragmented history, organizational barriers to definitive testing in unstable patients, competing pathophysiology, and diagnostic masking by early corticosteroids. (3) Strategies: Clinicians used a sepsis-first safety net with broad antibiotics and organ support, followed either by reactive re-evaluation for nonresponse or by early parallel work-up to secure mimic-specific tests before steroid administration. (4) Triggers: Re-evaluation was prompted when the clinical course or physiology diverged from clinicians’ expectations of typical sepsis, including discrepant hemodynamics, atypical temporal patterns of fever, focal physical signs, and metabolic abnormalities that felt disproportionate to presumed infection. Conclusions In ICUs, sepsis mimics are clinically important yet difficult to recognize because of both phenotypic overlap with sepsis and context-dependent constraints. While a sepsis-first approach preserves safety, our findings suggest that early parallel evaluation may help shorten time to the correct diagnosis. These insights support targeted debiasing education, multidisciplinary diagnostic pathways, and quantitative studies to clarify epidemiology and the timing-sensitive harms of delayed recognition.

RATIONALE: A routine clinical practice in adult critically ill patients receiving invasive mechanical ventilation (IMV) may be difficult to define. Our goal was to report updated global, and country-specific estimates of incidence, mortality, and case-fatality rates. METHODS: An observational prospective cohort of consecutive adult patients admitted between October 1, 2022, and April 30, 2023 to 457 intensive care units (ICU) from 42 countries who received IMV longer than 12 hours. Data were collected on each patient at initiation of mechanical ventilation and daily throughout the course of IMV for up to 28 days. RESULTS: During the period of recruitment, 8,350 patients were enrolled. A total of 6,998 patients from lower-middle income countries (1,428 patients), upper-middle countries (1930 patients) and high-income countries (3,640 patients) were included. Patients were predominantly males (63%) with a median age of 64 years (IQR 50,74) and median SAPS3 64 points (IQR 52-77). Main reasons for IMV were: neurologic disease (20%), postoperative respiratory insufficiency (16%), community acquired pneumonia (10%), sepsis (9%), cardiac failure (7%), ARDS (6%), COPD (5%), nosocomial pneumonia (5%), COVID (3%). Ventilator setting registered were: Tidal volume (median, IQR 7.4; 6.6-8.3 ml/kgPBW), plateau pressure (18; 15-22 cmH2O), applied PEEP (6; 5-8 cmH2O), driving pressure (12; 9-15 cmH2O), mechanical power (15.7; 11.9-20.8 joules/min). A lung protective strategy was applied on 79% of monitoring days and an open Lung Approach on 25% of monitoring days. Patients received sedation on 80% of the monitored days, analgesia on 77% and neuromuscular blocking on 9%. Most prevalent complications during the course of mechanical ventilation were sepsis (17%), delirium (14%), ventilator-associated pneumonia (8%), ARDS (8%) and ICU acquired weakness (8%). Other complications as thromboembolic events, tracheobronchitis, bleeding ulcus stress or Clostridium infection had a prevalence lower than 2%. 73% of the patients had at least one organ dysfunction, the most frequent of which were cardiovascular failure (66%), renal failure (24%), hematological failure (12%) and hepatic failure (9%). Comparison of outcomes according to income country is shown in table 1. CONCLUSIONS: After the pandemic COVID-19, we found significant geo-economic differences in the clinical outcomes of critically ill patients requiring IMV. Further adjusted models will provide information about the usual care of mechanically ventilated patients and variables related with poor outcomes.

The 2024 revised edition of the Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock (J-SSCG 2024) is published by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine. This is the fourth revision since the first edition was published in 2012. The purpose of the guidelines is to assist healthcare providers in making appropriate decisions in the treatment of sepsis and septic shock, leading to improved patient outcomes. We aimed to create guidelines that are easy to understand and use for physicians who recognize sepsis and provide initial management, specialized physicians who take over the treatment, and multidisciplinary healthcare providers, including nurses, physical therapists, clinical engineers, and pharmacists. The J-SSCG 2024 covers the following nine areas: diagnosis of sepsis and source control, antimicrobial therapy, initial resuscitation, blood purification, disseminated intravascular coagulation, adjunctive therapy, post-intensive care syndrome, patient and family care, and pediatrics. In these areas, we extracted 78 important clinical issues. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members. As a result, 42 GRADE-based recommendations, 7 good practice statements, and 22 information-to-background questions were created as responses to clinical questions. We also described 12 future research questions.

Vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic (VEXAS) syndrome is a recently discovered severe disorder that predominantly affects adult males, characterized by systemic inflammation and hematologic abnormalities. Despite its profound impact on patient outcomes, awareness of VEXAS syndrome among critical care providers remains severely limited, often leading to delayed recognition, diagnosis, and initiation of appropriate treatment. This study aims to address this knowledge gap by conducting a scoping review on VEXAS syndrome in the critical care setting. This scoping review followed the PRISMA-ScR guidelines and Joanna Briggs Institute methodology, analyzing data from Cochrane CENTRAL, MEDLINE via PubMed, EMBASE, and Web of Science on May 19, 2024. We included studies that reported clinical features and treatments of patients with VEXAS syndrome requiring critical care. Of the 1262 reports identified, 78 reports met the inclusion criteria, including 45 case reports/series, 17 observational studies, 15 reviews, and one systematic review. Analysis of 55 cases revealed a median age of 69 with a strong male predominance (54/55). ICU admission rates ranged from 28 to 33

BackgroundLong-term physical dysfunction common among intensive care unit (ICU) survivors and mortality remains a concern even after hospital discharge. Although early identification of patients at risk for these outcomes is essential, few studies have investigated whether physical assessments at ICU discharge can predict physical dysfunction or death at 3, 6, and 12 months after discharge. The purpose of this study was to examine the association between physical assessment at ICU discharge and the incidence of physical functional disability or death within 12 months after discharge.MethodsThis was a multicenter prospective cohort study of 21 ICUs in Japan. Patients with sepsis admitted to the ICU for >48 h were enrolled. The primary outcome was physical dysfunction (Barthel index ≤90) or death at 3, 6, and 12 months after discharge. Physical assessments at the time of ICU discharge included the Medical Research Council (MRC) score, handgrip strength, and the Barthel index. A multiple logistic regression model and area under the curve (AUC) were used.ResultsIn total, 300 ICU patients (median age, 74 years) were included. MRC score (odds ratio [OR]: 0.98, 95% confidence interval [CI]: 0.96-0.99, cut-off: 46), hand grip strength (OR: 0.95, 95%CI: 0.92-0.98, cut-off: 12.0 kg), and Barthel index (OR: 0.96, 95%CI 0.95-0.98, cut-off: 15) were independent predictors of physical dysfunction or death at 12 months after hospital discharge and at 3 and 6 months. The Barthel index at ICU discharge showed the highest AUC for physical function or death at 12 months (0.718). The Barthel index and hand grip strength were also associated with cognitive dysfunction or mental disorders.ConclusionsIn ICU patients with sepsis, clinically available physical and muscle strength assessments at ICU discharge were significantly associated with physical dysfunction incidence or death over the first year of hospital discharge.Trial registration number: UMIN000041433.

OBJECTIVE:Sepsis often leads to heterogeneous symptoms of post-intensive care syndrome (PICS) composing physical, cognitive, and psychiatric disabilities, resulting in deteriorated quality of life (QoL), with limited interventions. This study aimed to identify phenotypes of sepsis-associated PICS by physical, cognitive, and psychiatric function and QoL at hospital discharge. DESIGN:A prospective observational study. SETTING:Twenty-one mixed ICUs. PATIENTS:All consecutive adult patients between November 2020 and April 2022, diagnosed with sepsis at ICU admissions and survived discharge, were enrolled. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:Phenotyping with clusters determined by three approaches was performed with following variables at hospital discharge: Barthel Index (<= 90 defined physical PICS), Short Memory Questionnaire (< 40 defined cognitive PICS), Hospital Anxiety and Depression Scale (>= 8 defined psychiatric PICS), Impact of Event Scale-Revised (>= 25 defined psychiatric PICS), EuroQoL 5-dimension 5-level, Clinical Frailty Scale hand-grip strength, and Medical Research Council. Each disability, employment, destination, and survival, were followed over the first year of hospital discharge. In total, 220 ICU patients were included (median age: 72.5 yr, 129 males (59%), 166 septic shocks (75%), and median Sequential Organ Failure Assessment Score: 8). Four phenotypes were identified: group 1 (n = 62) with no PICS, group 2 (n = 55) with mild PICS (physical and cognitive), group 3 (n = 53) with moderate PICS (all domains), and group 4 (n = 50) with severe PICS (all domains). Functional decline and recovery significantly varied among the phenotypes. Physical and cognitive PICS in group 2 improved by the 3-month follow-up, whereas the disabilities in groups 3 and 4 remained over the year. Psychiatric PICS in groups 3 and 4 ameliorated, whereas depression symptoms in group 4 were still evident at the 12-month follow-up. All groups showed persistent moderate to severe reduced QoL and low employment (0-50%). The survival in group 4 continuously decreased. CONCLUSIONS:Four clinical phenotypes of ICU sepsis survivors might contribute to a deeper understanding of post-sepsis trajectories and an individualized treatment approach.

OBJECTIVES:The spillover impact of the COVID-19 pandemic on patients without COVID-19 in ICUs should be assessed. We aimed to assess the association of ICUs' medical burden and capacity changes with clinical outcomes in such patients during the COVID-19 pandemic. DESIGN:Retrospective cohort study. SETTING:Twenty-three ICUs in Japan. PATIENTS:Patients without COVID-19 in ICUs from January 2019 to February 2023. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:These ICUs completed a web-based questionnaire on medical burden and capacity limitations in November 2023, and they were classified as having a limited capacity if their scores exceeded the median; otherwise, they were categorized as having a maintained capacity. The primary outcome was the standardized mortality ratio (SMR), calculated with the Acute Physiology and Chronic Health Evaluation III-j model, compared with the pre-pandemic level. Using individual-level patient data, a generalized linear Poisson mixed-effects model including an offset-time term was employed to assess the association of capacity limitation, the number of patients with COVID-19, and ICU bed occupancy on the day of admission, with hazard ratios for in-hospital death. Nine and fourteen ICUs had a limited capacity (25,568 patients) and a maintained capacity (45,068 patients), respectively. SMRs increased in four epidemic waves in the ICUs with a limited capacity but in only one wave in those with a maintained capacity. After adjustment, capacity limitation (hazard ratio, 1.19; 95% CI, 1.01-1.41; p = 0.04) and the number of patients with severe COVID-19 (per five patients; hazard ratio, 1.09; 95% CI, 1.03-1.16; p = 0.002) were associated with in-hospital mortality, but ICU bed occupancy was not. CONCLUSIONS:SMRs increased more frequently in ICUs with a limited capacity during the pandemic. Our findings emphasize the need for proactive strategies to mitigate medical burden and capacity limitations for future preparedness.

BACKGROUND:Extracorporeal membrane oxygenation (ECMO) is a vital intervention in patients with severe cardiogenic shock or respiratory failure who are unresponsive to conventional therapies. Despite advances in ECMO technology and management, complications such as infections, renal dysfunction, and post-intensive care syndrome remain significant challenges that contribute to high mortality. Existing registries have provided valuable insights but lack detailed data on infection management, rehabilitation practices, and other granular aspects of ECMO care. The Japan Intensive Care ECMO Consortium: Nationwide Effort for ECMO Care Optimization and Excellence (ECMO NEXT) study aims to address these gaps by establishing a comprehensive multicenter study in Japan. METHODS:This is a multicenter, retrospective cohort study conducted at 22 healthcare institutions in Japan, with data collected on ECMO cases between January 2018 and December 2023. Adults aged ≥18 years who underwent ECMO in the intensive care unit (ICU) during this period will be eligible. This study will focus on six predefined themes: post-decannulation fever, infection epidemiology, ventilator settings, ECMO-associated acute kidney injury and electrolyte abnormalities, rehabilitation practices, and venoarterial ECMO in toxicological emergencies and septic shock scenarios. Data-including clinical course, laboratory results, rehabilitation details, and outcomes-will be collected using a standardized electronic case report form on the Research Electronic Data Capture platform. Statistical models, including propensity score-based analyses, will be used to adjust for confounders and assess attributable risks. CONCLUSIONS:The ECMO NEXT study provides high-resolution data to address the gaps in ECMO research, particularly in ICU management and post-ECMO recovery.

Sepsis is a leading cause of death in intensive care units (ICU). Sepsis survivors are often left with significant morbidity, termed post-intensive care syndrome (PICS), impacting post-sepsis life. The aim was to present detailed data on the prognostic and functional long-term outcomes of ICU patients with sepsis in Japan, which is currently lacking and therefore prevents development of targeted solutions. A multicenter prospective study, involving 21 ICUs in 20 tertiary hospitals in Japan, included all consecutive adult ICU patients between November 2020 and April 2022, and diagnosed with sepsis at ICU admission (Sepsis 3). Follow-ups were performed at 3, 6, and 12 months after hospital discharge by telephone and mail. Primary outcome was death or incidence of PICS, defined by any of physical dysfunction (Barthel Index ≤ 90), cognitive dysfunction (Short Memory Questionnaire < 40), or mental disorder (any subscales for anxiety or depression of Hospital Anxiety and Depression Scale ≥ 8, or Impact of Event Scale-Revised ≥ 25). Secondary outcomes included Quality of Life (QOL), employment, and use of hospital, emergency, rehabilitation, and psychiatric services. A multivariable analysis investigated independent factors associated with each dysfunction at each follow-up. A total of 339 patients were included (median age 74 [67–82] years, 60

The Japanese Clinical Practice Guidelines for the Management of Sepsis and Septic Shock 2024 (J-SSCG2024) were developed to improve the standardization and quality of sepsis care across various clinical settings. However, real-world adherence to these recommendations among healthcare professionals in Japan remains unclear. The objective of this study was to assess patterns of adherence to the J-SSCG2024 and identify factors associated with variation in clinical practice. We conducted a nationwide web-based cross-sectional survey targeting healthcare professionals, administering a questionnaire that included 23 items reflecting the key J-SSCG2024 recommendations for the initial management of sepsis, along with demographic and professional background information. Cluster analysis was performed to identify the distinct adherence patterns. Subgroup analyses were conducted to explore the association between respondent characteristics and guideline compliance. Additionally, sensitivity analyses were performed to evaluate the robustness of the findings across distinct cluster numbers. A total of 734 healthcare professionals participated in the survey, most of whom were physicians (92.4

OBJECTIVES:To evaluate the impact of hospital-level median door-to-extracorporeal cardiopulmonary resuscitation (ECPR) time on survival and neurologic outcomes in patients with out-of-hospital cardiac arrest (OHCA) requiring ECPR. DESIGN:Secondary analysis of the Japanese Association for Acute Medicine OHCA registry, a nationwide Japanese database of OHCA patients. SETTING:Fifty-three hospitals across Japan. PATIENTS:Adult patients who underwent ECPR between 2014 and 2021 were included. Hospitals were categorized into "rapid" or "delayed" groups based on their median door-to-ECPR times. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:The primary outcome was 30-day survival. Secondary outcomes included 30-day and 90-day survival with favorable neurologic outcomes. Propensity score weighting was applied to adjust for confounders. In total, 2136 patients treated at 53 hospitals were included. Hospitals with shorter median door-to-ECPR times had higher 30-day survival rates (odds ratio [OR], 1.36; 95% CI, 1.21-1.53). Neurologic outcomes were better in the rapid hospital group at both 30 days (OR, 1.47; 95% CI, 1.24-1.73) and 90 days (OR, 1.47; 95% CI, 1.25-1.73) follow-ups. CONCLUSIONS:Hospital-level median door-to-ECPR time is a crucial predictor of survival and neurologic outcomes in OHCA patients requiring ECPR. Shorter door-to-ECPR times should be considered a key quality metric for ECPR processes.

BACKGROUND: Bleeding and thromboembolic complications are significant challenges in the treatment of patients with cardiogenic shock (CS) who require venoarterial extracorporeal membrane oxygenation (VA-ECMO). Anticoagulation strategies that target higher activated partial thromboplastin time (aPTT) may exacerbate bleeding and lead to poor outcomes. However, there is a lack of sufficient randomized trials to determine the optimal aPTT target for this patient population. RESEARCH QUESTION: Does anticoagulation management with a lower aPTT target range improve outcomes compared with a higher aPTT target range in patients with CS who are treated with VA-ECMO? STUDY DESIGN AND METHODS: The Target for Anticoagulation in the Management of Venoarterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock (TARGET-ECMO) trial is a multicenter, randomized controlled trial designed to evaluate the impact of different aPTT target ranges on outcomes in patients with CS who are treated with VA-ECMO. Patients are randomized into 1 of 2 groups: a lower aPTT target group (aPTT, 1.5 to1.8 times) or a higher aPTT target group (aPTT, 2.2 to 2.5 times). RESULTS: The primary end point is a hierarchic composite outcome assessed at 7 days that consists of (1) death from any cause, (2) major bleeding, (3) thromboembolic events, and (4) total transfusion of RBC concentrates, which are evaluated with the use of a win ratio. INTERPRETATION: Anticoagulation targets in VA-ECMO management typically are determined at the discretion of individual centers and clinicians. The Target for Anticoagulation in the Management of Venoarterial Extracorporeal Membrane Oxygenation for CS trial aims to improve the prognosis of patients with CS who are treated with VA-ECMO by exploring optimal aPTT target range for anticoagulation management. CLINICAL TRIAL REGISTRATION: Certified Review Board of Nagoya University Hospital (approval number: 2024-0166) and the Japan Registry of Clinical Trials (jRCT1041240069). CHEST Critical Care 2025; 3(4):100198

Background:The simplicity of the diagnostic definition of acute respiratory distress syndrome (ARDS) has led to its diagnosis in patients with new-onset or exacerbation of diffuse parenchymal lung diseases (DPLDs). This study investigated the incidence of DPLDs in patients with acute hypoxic respiratory failure who met the Berlin definition. Methods:This Japan-based multicentre retrospective cohort study included patients on mechanical ventilation who met the Berlin definition. For all participants, diagnosis was made by pulmonology specialists in DPLD and thoracic radiology (blinded to clinical diagnoses) by reviewing an extensive database designed for DPLD diagnosis across 10 participating hospitals. Results:Of 13 612 patients admitted to the intensive care unit during the study period, 272 met the Berlin definition of ARDS and were included for analysis. All underwent at least one chest computed tomography scan; none underwent lung biopsy. Briefly, 182 were designated classic ARDS (67%), 69 non-IPF (idiopathic pulmonary fibrosis) DPLDs (25%) and 21 IPF (8%) by DPLD specialists. Of the 90 patients diagnosed with DPLD (IPF or non-IPF) by specialists, 35% were diagnosed with classic ARDS by intensivists at the end of the clinical course. Diagnostic classifications of classic ARDS and IPF by DPLD specialists were associated with time-to-death (adjusted hazard ratio (HR) 1.58 (95% CI 1.03-2.45), p=0.038, and adjusted HR 1.73 (95% CI 1.01-2.97), p=0.045, respectively) and in-hospital mortality (adjusted HR 1.54 (95% CI 1.06-2.23), p=0.022 for classic ARDS) versus non-IPF DPLDs; intensivist diagnostic classifications were not. Conclusion:Approximately one-third of patients within the Berlin definition were retrospectively diagnosed with new-onset or acutely exacerbated DPLD by specialists.

Sepsis is caused by the body’s dysregulated response to infection, which can lead to multiorgan injury and death. Patients with sepsis may develop acute cardiac dysfunction, termed septic cardiomyopathy, which is a global but reversible dysfunction of both sides of the heart. This narrative review discusses the mechanistic changes in the heart during septic cardiomyopathy, its diagnosis, existing treatment options regarding severity and course, and emerging treatment approaches. Although no standardized definition for septic cardiomyopathy exists, it is described as a reversible myocardial dysfunction that typically resolves within 7 to 10 days. Septic cardiomyopathy is often diagnosed based on electrocardiography, cardiac magnetic resonance imaging, biomarkers, and direct invasive and noninvasive measures of cardiac output. Presently, the treatment of septic cardiomyopathy is similar to that of sepsis, primarily focusing on acute interventions. Treatments for cardiomyopathy often include angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and diuretics. However, because of profound hypotension in sepsis, many cardiomyopathy treatments are contraindicated in patients with septic cardiomyopathy. Substantial efforts have been made to study the pathophysiological mechanisms and diagnostic options; however, the lack of a uniform definition for septic cardiomyopathy is challenging for physicians when considering treatments. Another challenge for physicians is that the treatment for septic cardiomyopathy has only focused on acute intervention, whereas the treatment for other cardiomyopathies has been provided on a long-term basis. A better understanding of the underlying mechanisms of septic cardiomyopathy may contribute to the development of a unified definition of the condition and novel treatment options.