OBJECTIVE:A definition of refractory septic shock is necessary to guide diagnosis, management, prognostication, research, and future guidelines for this most severe form of the disease. We sought to achieve consensus on clinical criteria that would be used to define refractory septic shock. DESIGN:Review of literature, expert panel position statements, and Delphi rounds with an international expert group. SETTING:Consensus was defined as having at least 75% of panellists in agreement or disagreement on the three highest or lowest levels of a 7-point Likert scale or based on responses to single- or multiple-choice questions, respectively. SUBJECTS:A panel of multinational, multiprofessional and multidisciplinary critical care experts assembled by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine (57 invitations and 56 participants). MEASUREMENTS AND MAIN RESULTS:A five-round Delphi process was conducted for consensus and stability. The steering committee proposed 34 statements, and five of them were rejected by panel experts after round 2. Among 29 statements selected from eight domains, consensus was reached for 13. The panel agreed on the need for a comprehensive consensus set of clinical criteria for refractory septic shock. Markers of organ dysfunction (75%, 2 rounds), tissue perfusion (91.1%, 2 rounds) including lactate (94.6%, 2 rounds) and capillary refill time (76.8%, 2 rounds), assessment of fluid-responsiveness after initial resuscitation (92.9%, 5 rounds), and use of vasoactive drugs at norepinephrine equivalents greater than 0.5 µg/kg/min (75.0%, 3 rounds), were selected as clinical criteria of refractory septic shock. The use of critical care ultrasound (CCUS) (92.9%, 3 rounds) was the single diagnostic modality that reached a consensus-based agreement. CONCLUSIONS:A consensus for 13 criteria to frame the definition of refractory septic shock was reached. Refractory septic shock is characterised by persistently elevated lactate concentrations and or prolonged capillary refill time in patients with septic shock who are fluid unresponsive, require a norepinephrine base equivalent dose greater than 0.5 micrograms per kilogram per minute, and undergo CCUS assessment when mixed shock is suspected.

OBJECTIVES:. To summarize the effectiveness of critical care ultrasonography (CCUS) in adult patients with cardiogenic shock vs. standard of care without CCUS on patient-relevant outcomes. DESIGN:. We performed a scoping review across MEDLINE, Embase, CENTRAL, World Health Organization, International Clinical Trials Registry, ClinicalTrials.gov, and published and unpublished sources from inception until February 2024. SETTING:. The emergency department, ward, or ICU. PATIENTS:. We included randomized clinical trials (RCTs) and observational studies comparing CCUS to non-CCUS care in adult patients with cardiogenic shock. We included any type of ultrasound measure for the intervention in adult patients (≥ 18 yr old). INTERVENTIONS:. CCUS. MEASUREMENTS AND MAIN RESULTS:. We included two RCTs (n = 573 patients) and one observational study (n = 30 patients). RCT data suggested that CCUS, with transesophageal echocardiography in particular, in adult patients with cardiogenic shock may shorten time to resolution of hemodynamic instability at 72 hours (subhazard ratio [SHR], 1.26; 95% CI, 1.02–1.55) but failed to influence mortality (risk difference, –0.03; 95% CI, –0.1 to 0.05), time to resolution of hemodynamic instability within 6 days (SHR, 1.20; 95% CI, 0.98–1.46), ICU length of stay (LOS; p = 0.87), hospital LOS (p = 0.91), duration of mechanical ventilation (p = 0.73), or duration of renal replacement therapy (RRT; p = 0.68). CONCLUSIONS:. In adult patients with cardiogenic shock, CCUS does not impact mortality, time to resolution of hemodynamic instability within 6 days, ICU and hospital LOS, nor mechanical ventilation or RRT duration. Notably, CCUS may hasten resolution of hemodynamic instability at 72 hours, but such evidence is limited by imprecision and indirectness.

Emergency physicians frequently manage critically ill patients, often in settings without immediate access to critical care specialists. The Canadian Association of Emergency Physicians (CAEP) Critical Care Committee develops knowledge translation tools, clinical practice guidelines, and educational resources to support emergency physicians in delivering high-quality critical care. This national survey assessed emergency physicians’ preferences and needs related to critical care education and support. We conducted a cross-sectional, survey-based study of Canadian emergency physicians attending the International Conference on Emergency Medicine (ICEM) in Montreal, Quebec, between May 23 and May 28, 2025. Eligible participants were current CAEP members practicing in Canada. The survey was administered anonymously using a secure online platform. Responses were analyzed descriptively, and open-ended responses were reviewed to identify common themes using a descriptive content analysis approach. Of 702 clinicians approached, 215 completed the survey (31

Combat and sport require individuals to be ready for successful completion of the task at hand. Cognitive readiness and attention may be impaired for many reasons, including concussion or subconcussive injury, insufficient sleep, fatigue, or any other disruption or deviation of baseline physiology. While rapid readiness screening may identify individuals who are not "ready" for a given task, it is also important to find interventions which can rapidly return an individual to a state of readiness. Although general health practices such as nutrition, physical conditioning, and adequate rest support overall performance, targeted interventions-focused on oculo-vestibular, verbal-cognitive function, and motor control-may accelerate return to readiness. Additional modalities such as structured sleep optimization protocols, controlled stimulant use, and specific supplements may also contribute to rapid restoration. This paper describes an evidence-based framework for developing guidelines that identify, evaluate, and implement rapid readiness restoration strategies across diverse preclinical settings, including military far-forward environments, sports sidelines, and garrison or training contexts.

RATIONALE:Neuromuscular blocking agents (NMBAs) show potential benefits on mortality and other complications of acute respiratory distress syndrome (ARDS) in adult patients. Evidence-based decisions and processes ensure appropriate use of neuromuscular blockade in adult patients with ARDS. OBJECTIVES:The objective of these guidelines was to develop evidence-based recommendations for the administration of NMBAs in critically ill adult patients with ARDS. DESIGN:The American College of Critical Care Medicine Board convened a 21-member multidisciplinary panel of experts in critical care medicine, nursing, respiratory therapy, pharmacology, surgery, neurology, and anesthesiology. The panel included two expert methodologists specialized in developing evidence-based recommendations in alignment with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Conflict-of-interest policies were strictly followed during all phases of guidelines development including task force selection and voting. METHODS:The panel members identified and formulated five Population, Intervention, Comparison, and Outcome questions. We conducted a systematic review for each question to identify the best available evidence, statistically analyzed the evidence, and assessed the certainty of the evidence using the GRADE methodology. We used the GRADE evidence-to-decision framework to formulate the recommendations. RESULTS:The panel generated two conditional recommendations. One recommendation is to use NMBAs in adults with ARDS with Pao2/Fio2 less than 150. For the other recommendations, there was equipoise in the recommendation for and against using titratable vs. fixed-dose NMBA dosing, a monitoring-based strategy for assessing depth of sedation and analgesia in adults with ARDS before initiating or while receiving neuromuscular blockade, and administration of NMBAs for patients who are proned, due to overall lack of evidence in critically ill patients and due to considerations of patient safety and experience concerns. CONCLUSIONS:These guidelines provide additional perspectives on the use of NMBA in patients with ARDS, recognizing that institutional and patient-specific considerations must help to guide the decision-making process.

In combat and sport, there is an urgent need to identify readiness for performance to decide on removal from and return to activity. Cognitive readiness, including attention, can be impaired for many potentially coexisting reasons, including concussive or subconcussive injury, insufficient sleep/fatigue, and intoxication. Standard tests of concussion, sleep deprivation, and intoxication are often lengthy or require specialized skill or equipment to conduct. The ideal readiness screen should predict readiness or be associated with surrogate measures of readiness, be sensitive to multiple conditions that may impair readiness, and be reliable and rapid. This study outlines the methodology for an evidence-based process to develop multimodal rapid screening tests for readiness that are applicable across a broad range of environments, including military far-forward/sports sideline, garrison, and clinic.

Background Tracheal intubation is a common yet high risk procedure in the critically ill with as many as half experiencing peri-intubation adverse outcomes. Research Question We aimed to evaluate the comparative effectiveness and safety of various sedative agents used for endotracheal intubation of the critically ill patient in the emergency department, intensive care unit, operating room, and pre-hospital setting. Study Design & Methods We conducted a network meta-analysis and systematic review of randomized controlled trials. We searched MEDLINE, EMBASE, PubMed, Cochrane, and trial registries from inception to December 10, 2025 for Randomized controlled trials (RCTs) comparing two or more sedative agents in critically ill adults or children undergoing endotracheal intubation. Outcomes of interest were hemodynamic instability during intubation, hypoxemia, cardiac arrest, mortality, intensive care unit and hospital length of stay, vasopressor use, adrenal insufficiency, and first-pass success. Reviewers screened, extracted data, and assessed risk of bias using the Cochrane RoB 2 tool independently and in duplicate. We performed frequentist random-effects model network meta-analysis and used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to rate certainty in estimates. Results We included 21 RCTs enrolling 6,031 patients across Intensive Care Unit, Emergency Department, Operating Room, and pre-hospital settings. Compared with etomidate, there is probably more hemodynamic instability during intubation with ketamine (RR 1.31, 95% CI 1.15-1.48; moderate certainty). Ketamine-propofol may decrease hemodynamic instability during intubation compared with etomidate (RR 0.44, 95% CI 0.27-0.72; low certainty) and ketamine (RR 0.34, 95% CI 0.21-0.56; low certainty). Compared with etomidate, ketamine may decrease the need for the initiation of post-intubation continuous infusion vasopressors (RR 0.80, 95% CI 0.50-1.28; low certainty). Etomidate caused increased adrenal suppression compared with other agents. Interpretation When considering sedation agents for endotracheal intubation of the critically ill, etomidate probably causes less hemodynamic instability during intubation when compared with ketamine. However, etomidate may increase the need for the initiation of post-intubation continuous infusion vasopressors when compared with ketamine and increases adrenal suppression. The clinical importance of these competing effects remains uncertain. Ketamine-propofol may decrease hemodynamic instability during intubation when compared with etomidate and ketamine though the available evidence is too limited and uncertain to support firm conclusions and further randomized trials are needed.

OBJECTIVES:. We conducted a systematic review and meta-analysis to compare continuous ketamine infusion to other analgosedatives in critically ill children receiving invasive mechanical ventilation (IMV). DATA SOURCES:. We searched four electronic databases and trial registries to September 1, 2025. We searched published conference abstracts from two major critical care conferences (2022 to 2025). STUDY SELECTION:. We preregistered the protocol on PROSPERO (CRD42025631768). Reviewers screened abstracts and full texts independently and in duplicate. We included randomized controlled trials (RCTs) and nonrandomized studies comparing ketamine to other analgosedatives in critically ill children receiving IMV. Data Extraction:. Independently and in duplicate, we conducted data extraction. We assessed risk of bias using the Risk Of Bias instrument for Use in SysTematic reviews for RCTs or Risk Of Bias In Nonrandomized Studies of Interventions tool, and certainty of evidence using Grading of Recommendations, Assessment, Development, and Evaluation. We pooled data using random-effects models. DATA SYNTHESIS:. We included three RCTs and five nonrandomized studies (n = 1436 participants). Pooled analysis demonstrated that ketamine may have no effect on IMV duration (mean difference, 0.00 d; 95% CI, 0.03 d fewer to 0.03 d more; low certainty) and may reduce opioid exposure (mean difference, –8.88 µg/kg cumulative fentanyl equivalents; 95% CI, –6.99 to –10.77; low certainty). We found an uncertain effect of ketamine on delirium, withdrawal, length of stay, clinically important hypotension, and mortality compared with other analgosedatives. Long-term outcomes were not measured in included studies. CONCLUSIONS:. There is a paucity of studies examining ketamine analgosedation in children receiving IMV, yielding mostly very low certainty evidence for patient-important outcomes due to imprecision and issues related to serious risk of bias of included studies. Methodologically rigorous RCTs are needed to better understand the potential role of ketamine analgosedation in the PICU.

OBJECTIVE:This European Society of Intensive Care Medicine (ESICM) guideline provides evidence-based recommendations on the volume of early resuscitation fluid for adult critically ill patients. METHODS:An international panel of experts developed the guideline, focusing on fluid resuscitation volume in adult critically ill patients with circulatory failure. Using the PICO format, questions were formulated, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was applied to assess evidence and formulate recommendations. RESULTS:In adults with sepsis or septic shock, the guideline suggests administering up to 30 ml/kg of intravenous crystalloids in the initial phase, with adjustments based on clinical context and frequent reassessments (very low certainty of evidence). We suggest using an individualized approach in the optimization phase (very low certainty of evidence). No recommendation could be made for or against restrictive or liberal fluid strategies in the optimization phase (moderate certainty of no effect). For hemorrhagic shock, a restrictive fluid strategy is suggested after blunt trauma (moderate certainty) and penetrating trauma (low certainty), with fluid administration for non-traumatic hemorrhagic shock guided by hemodynamic and biochemical parameters (ungraded best practice). For circulatory failure due to left-sided cardiogenic shock, fluid resuscitation as the primary treatment is not recommended. Fluids should be administered cautiously for cardiac tamponade until definitive treatment and guided by surrogate markers of right heart congestion in acute pulmonary embolism (ungraded best practice). No recommendation could be made for circulatory failure associated with acute respiratory distress syndrome. CONCLUSIONS:The panel made four conditional recommendations and four ungraded best practice statements. No recommendations were made for two questions. Knowledge gaps were identified, and suggestions for future research were provided.

Noninvasive positive pressure ventilation (NIV) is an important tool for treating the critically ill. Unfortunately, NIV intolerance is a potential reason why patients will fail NIV and have to be intubated and invasively mechanically ventilated. Providing sedation is a possible solution to improve intolerance. While many sedative/analgesic options exist such as dexmedetomidine, ketamine, opioids, benzodiazepines, or propofol, little research is available to guide these choices. Because of the paucity of data, there are no clinical practice guideline recommendations to assist the clinician.

Background: In the emergency setting, many diagnostic pathways incorporate change in high-sensitivity cardiac troponin (hs-cTn) concentrations (i.e., the delta) to classify patients as low-risk (rule-out) or high-risk (rule-in) for possible myocardial infarction (MI). However, the impact of analytical variation on the delta for correct classification is unknown, especially at concentrations below and around the 99th percentile. Our objective was to assess the impact of delta variation for correct risk classification across the European Society of Cardiology (ESC 0/1 h and 0/2 h), the High-STEACS, and the common change criteria (3C) pathways. Methods: A yearlong accuracy study for hs-cTnT was performed where laboratories across Canada tested three patient-based samples (level 1 target value = 6 ng/L, level 2 target value = 9 ng/L, level 3 target value = 12 ng/L) monthly across 41 different analyzers. The assigned low-delta between levels 1 and 2 was 3 ng/L (i.e., 9 − 6 = 3 ng/L) and the assigned high-delta between levels 1 and 3 was 6 ng/L (i.e., 12 − 6 = 6 ng/L). The low- and high-deltas for each analyzer were determined monthly from the measured values, with the difference calculated from the assigned deltas. The obtained deltas were then assessed via the different pathways on correct classification (i.e., percent correct with 95% confidence intervals, CI) and using non-parametric analyses. Results: The median (interquartile range) difference between the measured versus assigned low-delta (n = 436) and high-delta (n = 439) was −1 ng/L (−1 to 0). The correct classification differed among the pathways. The ESC 0/1 h pathway yielded the lowest percentage of correct classification at 35.3% (95% CI: 30.8 to 40.0) for the low-delta and 90.0% (95% CI: 86.8 to 92.6) for the high-delta. The 3C and ESC 0/2 h pathways yielded higher and equivalent estimates on correct classification: 95.2% (95% CI: 92.7 to 97.0) for the low-delta and 98.2% (95% CI: 96.4 to 99.2) for the high-delta. The High-STEACS pathway yielded 99.5% (95% CI: 98.4 to 99.9) of correct classifications for the high-delta but only 36.2% (95% CI: 31.7 to 40.9) for the low-delta. Conclusions: Analytical variation will impact risk classification for MI when using hs-cTn deltas alone per the pathways. The 3C and ESC 0/2 h pathways have <5% misclassification when using deltas for hs-cTnT in this dataset. Additional studies with different hs-cTnI assays at concentrations below and near the 99th percentile are warranted to confirm these findings.

BACKGROUND:A limitation of diagnostic algorithms in patients with suspected myocardial infarction (MI) is the requirement for assay-specific high-sensitivity cardiac troponin (hs-cTn) cutoff concentrations and change criteria. In this study we evaluated a common change criteria algorithm (3C) for hs-cTn and compared it with established algorithms for the rule out and rule in of MI. METHODS:We applied the 3C algorithm in 2 prospective cohort studies (with 3 different hs-cTn assays) of patients who presented to the emergency department with suspected MI who had serial hs-cTn results available. Diagnostic performance measures (sensitivity, specificity, predictive values, likelihood ratios) for MI were obtained for the 3C (change criteria > |3| ng/L for < 10 ng/L, > |30|% between 10 and 100 ng/L, and > |15|% for > 100 ng/L), and the European Society of Cardiology (ESC) algorithms for rule in and rule out. Confusion matrices, net reclassification improvement, and effectiveness (percentage rule in and rule out) analyses were also performed. RESULTS:In 5011 patients, the MI prevalence was 16.12% (n = 811). Comparable diagnostic accuracy in terms of sensitivity, specificity, and predictive values were observed between the 3C and ESC algorithms. Direct comparison of the algorithms via net reclassification improvement showed no decisive advantage for either algorithm. Confusion matrices for all 3 assays for the 0- and/or 1-hour and 0- and/or 2-hour sampling identified that the 3C ruled in more patients with an MI who were ruled out using the ESC algorithm. Effectiveness was higher for 3C (83.2%-88.8%) vs ESC (64.4%-74.5%) for hs-cTnI but not for hs-cTnT (64.5%-71.8% vs 72.4%-80.6%, respectively). CONCLUSIONS:The 3C algorithm offers a uniform, assay agnostic alternative to established algorithms, independent of timing of serial sampling. CLINICAL TRIAL REGISTRATIONS:NCT02355457, ACTR,12611001069943, ANZCTR12610000766011, and ANZCTR12613000745741.

Enteral nutrition (EN) has become the standard of care for nutritional support among critically ill patients. However, little is known about whether continuous delivery (CEN) or intermittent delivery (IEN) is preferable or the consequences of either strategy. This is particularly true for diarrhea, which is understudied but consistently shown to be associated with increased morbidity among critically ill patients. This is a multicenter, retrospective cohort study including critically ill patients greater than 18 years of age, admitted to the Intensive Care Unit in Hamilton, Canada, and prescribed EN for greater than 48 hours. Patients will be divided into IEN and CEN groups based on the nutritional strategy they received during their stay. The primary outcome will be the proportion of patients in each group with diarrhea during their ICU stay, diarrhea will be defined according to WHO criteria. Multivariate logistic regression will be performed to identify the role of covariates in the risk of developing diarrhea. Secondary outcomes will include caloric intake, incidence of ICU-acquired infections, including Clostridioides difficile, length of stay, and mortality. This study protocol has been approved by the Hamilton Integrated Research Ethics Board (#16453). The study findings will be disseminated at academic conferences and published in peer-reviewed journals.

OBJECTIVE:To determine the impact of using dynamic measures of fluid responsiveness in guiding the resuscitation of adult patients with sepsis and septic shock. DATA SOURCE:We searched MEDLINE, Embase, and unpublished sources from inception to February 3, 2025. STUDY SELECTION:We included randomized controlled trials (RCTs) that evaluated the use of dynamic measures of fluid responsiveness to guide resuscitation compared with any other method in patients with sepsis and septic shock. DATA EXTRACTION:We collected data regarding study and patient characteristics, definitions of fluid responsiveness, modality for assessing fluid responsiveness, and outcome data. We performed a random-effects meta-analysis and rated the certainty of the evidence using the Grading of Recommendations Assessment, Development, and Evaluation framework. DATA SYNTHESIS:We included nine eligible RCTs (n = 698 patients). The use of dynamic measures of fluid responsiveness to guide IV fluid (IVF) administration of patients with septic shock probably reduces 28-day mortality (relative risk] 0.61; 95% CI, 0.42-0.90, moderate certainty), may reduce the risk of acute kidney injury (AKI) (RR 0.66; 95% CI, 0.44-0.98, low certainty), and cumulative fluid balance on day 3 (mean difference -1.57L; 95% CI, -2.44 L to -0.69 L, low certainty). The use of dynamic measures of fluid responsiveness has an uncertain effect on ICU mortality, ICU and hospital length of stay, need for and duration of mechanical ventilation, need for renal replacement therapy, vasoactive medication administration, duration of vasopressor use, and IVF administration on day 1. CONCLUSIONS:In adult patients with sepsis and septic shock, using dynamic measures of fluid responsiveness may improve survival and reduce the risk of AKI. Future studies should evaluate the impact of this intervention on other important clinical outcomes and determine the comparative efficacy of specific modalities for assessing fluid responsiveness.

OBJECTIVES:To determine the safety and efficacy of critical care ultrasonography (CCUS) guided volume management in acutely ill patients. DATA SOURCES:We searched MEDLINE, Embase, Wiley CENTRAL, and unpublished sources from inception to February 6, 2024. STUDY SELECTION:We included randomized controlled trials (RCTs) of acutely ill adult patients randomized to receive CCUS as compared with no CCUS to guide fluid management. DATA EXTRACTION:Reviewers screened abstracts, full texts, and extracted data independently and in duplicate. We pooled data using a random-effects model, assessed the risk of bias using the modified Cochrane tool and assessed the certainty of evidence using the Grading Recommendations Assessment, Development, and Evaluation approach. DATA SYNTHESIS:We included 17 RCTs (n = 1765 patients) in this review. Pooled analyses found that the use of CCUS for volume management in acutely ill patients may decrease mortality at the longest reported time period (relative risk [RR], 0.79; 95% CI, 0.67-0.95; low certainty) and decreases the fluid balance up to 72 hours after admission (mean difference [MD], 0.72 L lower; 95% CI, 1.5 L lower to 0.07 L higher; low certainty). CCUS had an uncertain effect on duration of mechanical ventilation (MD, 1.14 d fewer; 95% CI, 3.35 d fewer to 1.07 d more; very low certainty), ICU length of stay (LOS) (MD, 0.01 d fewer; 95% CI, 1.12 d fewer to 1.09 d more; very low certainty), the need for vasopressors (RR, 0.39; 95% CI, 0.10-1.62; very low certainty), acute kidney injury (AKI) (RR, 0.94; 95% CI, 0.32-2.72; very low certainty), and the need for renal replacement therapy (RRT) (RR, 0.79; 95% CI, 0.17-3.66; very low certainty). CONCLUSIONS:In acutely ill adult patients, CCUS for the use of targeted volume management may reduce mortality and fluid balance up to 72 hours after admission. CCUS has an uncertain effect on ICU LOS, duration of mechanical ventilation, duration of vasopressor use, AKI, and the need for RRT. However, this evidence is limited by imprecision and indirectness.