Citations

Background Ketamine has demonstrated efficacy in treatment-resistant depression, primarily in psychiatric or outpatient populations. Its use in ICU patients remains underexplored, with limited data beyond case reports and small series. This study evaluated the association between subanesthetic ketamine infusions and improvement in depressive symptoms and hemodynamic changes in ICU patients. Methods We conducted a retrospective study of adults admitted to the ICU who received IV ketamine (0.3-0.75 mg/kg over 40 min on three consecutive days) for depressive symptoms. Changes in depressive symptoms were assessed using routine clinical documentation by physicians, nurses, and occupational and physical therapists. Hemodynamic parameters (blood pressure and heart rate) were recorded before and up to 120 min after infusion. The primary outcome was to evaluate depressive symptoms while the secondary outcome was to assess hemodynamic changes post transfusion. Results Thirty-four patients met criteria, including 18 solid organ transplant recipients. Median age was 59 years; 61.8% were male. Ketamine was associated with improvement in apparent sadness (90.0% vs 52.2%, P < .05) and reported sadness (95.0% vs 59.1%, P < .05). In transplant recipients, improvement in apparent sadness remained significant (80.0% vs 41.7%, P < .05). Hemodynamic parameters remained stable; heart rate increased transiently at 15-30 min post-infusion, returning to baseline by 60-90 min. Adverse effects observed were anxiety (12.5%), restlessness and/or agitation (10.4%), and dissociation (8.16%). Conclusion Subanesthetic ketamine improved specific depressive symptoms in critically ill ICU patients without significant hemodynamic instability. These findings support its potential as a rapid-acting antidepressant in the ICU, warranting further prospective trials.

Background and importance Emergency tracheal intubation in critically ill adults is associated with a high risk of peri-intubation adverse events, making first-attempt success a key safety target. Objective This study aimed to evaluate whether the use of neuromuscular blocking agents (NMBAs) improves the proportion of first-attempt success and reduces adverse events during emergent intubations outside the operating room. Methods This was a systematic review and meta-analysis of randomized clinical trials or nonrandomized studies comparing sedative-hypnotic plus NMBA versus sedative-hypnotic alone in critically ill adults undergoing emergency endotracheal intubation in nonoperative settings. Animal, cadaveric, manikin/simulation, and pediatric studies were excluded. Articles were screened on 21 August 2025, in Ovid MEDLINE, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, and the Web of Science Core Collection. Main results Of 4736 screened citations, 13 studies (8 cohort; 5 before-after studies) were included in the quantitative analysis, with 14 072 participants. NMBA use was associated with higher first-attempt success, which ranged from 69 to 92% (pooled odds ratio, 2.72; 95% onfidence interval: 1.42–5.21; low-certainty evidence). Secondary outcomes related to adverse events were rated as very low certainty due to sparse data, inconsistent reporting, and serious imprecision. Conclusion NMBA use during emergency intubation was associated with improved first-attempt success, although the certainty of evidence was low.

Purpose Survivors of critical illness often acquire significant physical, cognitive, and psychological burdens following their intensive care unit (ICU) stay, termed “post-intensive care syndrome” (PICS). Screening for PICS is generally not performed outside of research settings largely due to lack of a simple assessment tool and time constraints. Methods This was a prospective cohort study at a single academic medical center in the USA. We included adults (18 years or older) who spent greater than 48 h in any ICU within the medical center. Following transfer out of the ICU and at 3 months, psychological, cognitive, and physical functioning were assessed using the Hospital Anxiety and Depression Scale, Impact of Event Scale-Revised, Montreal Cognitive Assessment-blind, and Barthel Index. We compared these validated questionnaires to a brief, 15-item PICS screening tool (5 questions/domain) that was developed by our multidisciplinary study team and administered to study participants after ICU discharge to general care. The primary objectives of this study were to assess the ability of validated screening tools administered at ICU discharge to predict PICS at 3 months and develop a novel screening tool for identifying patients at risk of PICS. Major Findings 191 participants completed the initial questionnaire, and 109 (56%) completed the 3-month follow-up. PICS tool scores were compared to 3-month follow-up data from validated questionnaires to evaluate predictive performance. Overall, the screening tool weakly-to-moderately correlated with continuous outcomes of the validated measures at 3-month follow-up. When evaluating sensitivity and specificity for individual domains, the screening tool had an area under curve of >0.7 for all three domains, indicating moderate-to-good sensitivity and specificity. Conclusions We developed a brief PICS screening tool that is feasible to use without prior training that modestly predicted the development of PICS following ICU stay.

INTRODUCTION: A Model for End-Stage Liver Disease-lactate (MELD-LA) score is an independent predictor of inpatient mortality and organ failure validated in more than 8,600 patients across diverse settings. However, its utility in sepsis, particularly when combined with lactate clearance (LA clearance), has not been fully evaluated. In this study, we examined the dynamic role of MELD-LA with 24-hour LA clearance as a predictor of 30-day mortality in critically ill patients with cirrhosis and sepsis. METHODS: We analyzed cirrhosis patients with sepsis admitted to the intensive care unit (ICU) in a large US healthcare system (20 hospitals) from 2014 to 2022, examining MELD-LA and LA clearance within 24 hours as predictors of 30-day mortality. We externally validated our findings in the Asian Pacific Association for the Study of the Liver-acute-on-chronic liver failure Research Consortium, a multinational Asian cohort (31 centers) from 2009 to 2019. RESULTS: A total of 3,879 cirrhosis patients with sepsis were admitted to the ICU (43.2% female, 20.5% Hispanic, 12.4% on dialysis; mean initial LA 4.5 mmol/L, MELD 20.8, MELD-LA 17.6). Survivors showed a median lactate change of −1.04 (35% clearance) compared with −0.4 (12%) for nonsurvivors. LA clearance within 24 hours was influenced by the presenting MELD-LA. In the North American cohort, ≥35% LA clearance was associated with improved 30-day survival (odds ratio 0.41, 95% CI 0.31–0.53; P < 0.001). Similarly, in the Asian Pacific Association for the Study of the Liver cohort (n = 1,259), ≥35% clearance was linked to a 60% reduction in mortality (odds ratio 0.42, 95% CI 0.28–0.62; P < 0.001). When stratified by LA clearance, patients with LA clearance of ≥35% had a higher percentage of early administration of resuscitative measures than those with LA clearance of < 10% especially regarding early antibiotic administration (82.5% vs 67.6%; P value <0.001). DISCUSSION: Early reduction in initial LA by one-third predicts 30-day mortality and may indicate treatment response in cirrhosis patients with sepsis in the ICU. Combining MELD-LA and LA clearance early enables better risk stratification and informs management.

Abstract Background Critical illness is a risk factor for carnitine deficiency. Carnitine deficiency may result in serious medical complications and poor clinical outcomes. This study aimed to identify the prevalence and potential predictors of carnitine deficiency. Methods This was a descriptive cross‐sectional study conducted in a convenience sample of 144 critically ill adults admitted to a surgical or cardiovascular intensive care unit at the University of Utah Hospital, with serum carnitine levels measured from January 1, 2022, to December 31, 2024. Binary and multivariable logistic regression models were constructed to explore potential predictors of carnitine deficiency, which was defined as a free serum carnitine level <36 µmol/L. Results The mean age of patients was 56.5 years; 41.7% of the sample had carnitine deficiency. For each unit decrease in body mass index, the odds of developing carnitine deficiency increased by 5% compared with maintaining normal free carnitine status (odds ratio [OR], 0.95; 95% confidence interval [CI], 0.9–0.99). Those prescribed continuous renal replacement therapy were 2.43 times more likely to develop carnitine deficiency than those not on continuous renal replacement therapy (OR, 2.43; 95% CI, 1.12–5.25). Conclusion A high proportion of our study population had carnitine deficiency. Continuous renal replacement therapy and a lower body mass index were significant predictors in the multivariable model. Female sex and a history of chronic kidney disease may warrant further exploration based on significance in the univariable analysis.