CRT-Guided Strategy for Patients With Early Septic Shock
The personalized strategy led to a higher rate of CRT normalization within the first six hours.
A personalized hemodynamic resuscitation strategy targeting capillary refill time (CRT) was superior to usual care for the composite outcome of mortality, duration of vital support and hospital length of stay for patients with early septic shock.
“Personalized Hemodynamic Resuscitation Targeting Capillary Refill Time in Early Septic Shock: The ANDROMEDA-SHOCK-2 Randomized Clinical Trial,” an international trial in JAMA, notes that the CRT guided strategy outperformed usual care at 28 days.
In a personalized hemodynamic resuscitation (PHR) approach, fluids, vasopressors and inotropes were tailored using individualized assessments — including pulse pressure, diastolic arterial pressure, fluid responsiveness and bedside echocardiography. This strategy was applied to patients treated within the first four hours of septic shock.
Enrolled across 19 countries, 1,467 patients (mean age 66, 43.3% female) in 86 ICUs were assigned to either the CRT PHR group or usual care, which followed local protocols or international guidelines, with fluid responsiveness assessment and basic echocardiography permitted but not required. The personalized strategy led to a higher rate of CRT normalization within the first six hours (85.9% vs. 61.7%) and required less fluid, while early perfusion markers trended favorably compared to usual care.
The CRT guided advantage was driven largely by fewer days requiring vasoactive therapy, mechanical ventilation or kidney replacement therapy, the trial notes. Patients in the personalized group also showed faster improvement in organ dysfunction and more favorable early perfusion trends compared to usual care.
“The effectiveness of the CRT-PHR algorithm cannot be attributed to a single intervention (i.e., administered resuscitation fluids) but to the dynamic interaction between the individual components, which converged into a higher rate of CRT normalization,” the trial adds.
The trial lists several limitations, including an unblinded design, variability in bedside assessments and clinical decision-making, and heterogeneity in standard care across centers and countries.
Family-Led Delirium Assessment Tool Developed for Spanish Speakers
Spanish-FAM addresses concerns for Hispanic and Latino patients.
A delirium assessment method for Spanish-speaking ICU patients that relies on family caregivers’ observations outperformed usual care, offering clinicians a more accurate and culturally informed screening option for these patients.
“Addressing Language Barriers to ICU Delirium Detection,” in CHEST Critical Care, details how the Family Confusion Assessment Method (Family-CAM) was translated to address detection gaps among Hispanic and Latino patients. The structured multilingual review process included harmonization by bilingual physicians from multiple Spanish-speaking regions.
The resulting Spanish-Language Family-Confusion Assessment Method for the ICU (Spanish-FAM) preserves Family-CAM’s 11-item structure, guiding family caregivers to report on four core features of delirium: acute mental status change, inattention, disorganized thinking and altered level of consciousness.
The study enrolled 20 Spanish-speaking ICU patients and their family caregivers at the University of California, San Diego. Within the first day of admission, patients received three delirium assessments: the CAM-ICU completed by bedside clinicians as part of usual care, the Spanish-FAM completed by family caregivers, and a Spanish-language CAM administered by bilingual members of the study team.
Spanish-FAM performed on par with assessments by bilingual clinicians and far better than usual care, correctly identifying 85% of delirium cases and 71% of non-delirium cases. In contrast, usual care missed most delirium cases and frequently categorized patients as unable to assess.
The study notes that while bilingual providers can translate the CAM-ICU at the bedside, their numbers in the United States are limited, and translation alone cannot ensure the cross-cultural adaptation needed for accurate delirium assessment.
“Given these limitations, the Spanish-FAM offers a practical alternative that leverages family caregivers to help bridge language barriers to delirium detection,” the study notes.
With a sample of just 20 patients, the study acknowledges that further evaluation in a larger cohort is needed: Still, “these findings represent a critical first step toward more equitable ICU delirium screening practices.”
Infective Endocarditis: Challenges, Risk Factors and Clinical Presentation
It is imperative that infective endocarditis is detected early and managed promptly.
Clinicians should be aware of the challenges in diagnosing and treating patients with infective endocarditis as well as the changing risk factors, bacterial profile and clinical presentation, and the need for a multidisciplinary team.
“Current Diagnosis and Management of Infective Endocarditis in Adults,” in JNP: The Journal for Nurse Practitioners, notes that the infection’s increasing prevalence in younger patients and high mortality rate call for an understanding of its complexity and approaches to immediate treatments. “The treatment plan for infective endocarditis should be developed by an infective endocarditis multidisciplinary team in collaboration with patients considering contributing social factors such as support, resources, and behaviors,” notes the featured article.
The profiles of patients at risk for infective endocarditis have changed from primary association with rheumatic heart disease to include patients with poor dental habits as well as intravenous drug users (IVDU) ages 15 to 34, who had more than a 400% increase in related hospitalizations from 2005 to 2016. In addition, staphylococcus has replaced streptococcus as the primary responsible bacteria due to “the increased number of cardiac implantable electronic devices, prosthetic heart valves, intravascular catheters, exposures to the health care system, recent surgical procedures, and IVDU.”
The article encourages clinicians to be suspicious of infective endocarditis in patients with high fever, positive blood cultures and more than one common risk factor: “Owing to the high mortality rate, complex presentation, and need for antibiotic regimens targeting multidrug resistant organisms, it is imperative that infective endocarditis is detected early and treated promptly.”
Using a multidisciplinary team that includes cardiologists, infectious disease specialists, neurologists and cardiac surgeons, treating facilities should generally initiate broad-spectrum antibiotics (vancomycin is the “treatment of choice”). Early surgical interventions may be necessary, particularly for valve repair or replacement, and “should be scheduled within days of diagnosis in the absence of stroke with neurologic deficits,” the article adds.
New AHA Guidelines on Post-Cardiac Arrest Care
10 take home messages summarize actionable updates for bedside teams.
The American Heart Association’s (AHA’s) new guidelines on adult post-cardiac arrest care outline evidence based targets for blood pressure, oxygenation, ventilation and glucose management, emphasizing early physiologic stabilization to reduce secondary injury and support neurologic recovery.
“Post-Cardiac Arrest Care: 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care ,” in Circulation, reviews evidence on routine antibiotics after return of spontaneous circulation (ROSC) and updates guidance on diagnostic testing, temperature control and advanced cardiac interventions. The guidelines also clarify seizure detection and management, and provide updated recommendations on the timing and tools used for neuroprognostication.
Detailed information is supported by 10 take home messages that summarize actionable updates for bedside teams:
- Use a multimodal approach to neuroprognostication, incorporating neuron specific enolase and neurofilament light chain as serum biomarkers.
- Maintain temperature control for at least 36 hours in adults who remain unresponsive after ROSC.
- Computed tomography (CT), echocardiography or point of care ultrasound after ROSC may help identify causes of arrest or complications.
- Coronary angiography is recommended before discharge in survivors with suspected cardiac etiology.
- Avoid hypotension by targeting a mean arterial pressure of at least 65 mm Hg.
- Routine mechanical circulatory support is not recommended but may be considered in certain cases of refractory cardiogenic shock.
- Do not manage myoclonus without an EEG correlate.
- A trial of a nonsedating antiseizure medication may be reasonable for patients with ictal interictal EEG patterns.
- Before discharge, provide patients and their caregivers with structured assessment and referral for emotional support.
- Interventions to reduce healthcare professionals’ burnout may be beneficial.
A related article in PulmCCM offers a clinician focused take on one of the guidelines’ key themes: the role of early imaging after cardiac arrest. The guideline supports considering full body CT scanning to identify occult injuries or reversible causes, while acknowledging that evidence remains limited and practice varies across centers.
Clopidogrel vs. Aspirin for Patients With Coronary Artery Disease
Clopidogrel’s affordability and availability can make it easy to implement.
The findings of a systematic review and meta-analysis note that clopidogrel monotherapy is superior to aspirin monotherapy with no increased risk of bleeding, and they support the use of clopidogrel rather than aspirin for secondary prevention in patients with established coronary artery disease (CAD).
“Clopidogrel Versus Aspirin for Secondary Prevention of Coronary Artery Disease: A Systematic Review and Individual Patient Data Meta-Analysis,” in The Lancet, reviews seven randomized trials showing that patients with CAD who have stopped or never started dual antiplatelet therapy did not increase bleeding risk while taking clopidogrel. “These findings add to the evidence that clopidogrel monotherapy is superior to aspirin monotherapy … and support the preferential use of clopidogrel over aspirin for secondary prevention in patients with established CAD,” the review adds.
The trials included 28,982 patients divided between the two randomized treatments and a median follow-up period of 2.3 years. Most patients had undergone a coronary angioplasty or had experienced acute coronary syndrome.
Major adverse cardiovascular or cerebrovascular events occurred in 6.4% of patients taking clopidogrel (929 of 14,507) and 7.3% of patients taking aspirin (1,062 of 14,475), for a 14% reduction in risk overall. Death due to cardiovascular or any other reason and bleeding (major or gastrointestinal) did not differ between the groups.
The review, also available on ScienceDirect, notes that affordability and availability make clopidogrel easy to adopt in general practice: “The superior efficacy of clopidogrel versus aspirin was consistent across multiple key subgroups, including individuals with clinical features predictive of poor clopidogrel responsiveness, supporting the generalisability of these findings to the broad spectrum of patients with CAD.”
Nurses Key to Implementing Noninvasive Oxygenation Protocols
Successful noninvasive oxygen therapies depend on a patient-centered, evidence-based approach.
Noninvasive oxygen delivery strategies for critical care patients with respiratory failure offer effective alternatives to mechanical ventilation, but they carry risks of lung damage that require nurses to monitor safety and maintain protocols.
“Noninvasive Oxygenation Strategies in Critical Care: Applications and Challenges,” in AACN Advanced Critical Care, notes that nurses play a key role alongside respiratory therapists in the implementation of high-flow nasal cannula (HFNC) and noninvasive positive pressure ventilation (NIPPV). Nurses can provide ongoing monitoring of patient comfort and potential therapy failures. “Ultimately, the successful application of noninvasive oxygen therapies depends on a patient-centered, evidence-based approach,” the article notes.
After becoming standard care, based on necessity due to patient volumes and resource limitations during the COVID-19 pandemic, HFNC and NIPPV have since become frontline therapies with wide usage, protocols and training initiatives. “These noninvasive strategies not only helped reduce the burden on intensive care units but also improved patient outcomes by avoiding complications associated with intubation such as ventilator-associated pneumonia, ventilator-induced lung injury, and sedation-related delirium.”
Patient self-inflicted lung injury (P-SILI) remains a primary concern with both therapies, however, caused inadvertently by excessive respiratory drive. “The mechanisms underlying P-SILI closely resemble those of ventilator-induced lung injury, although they originate from the patient’s own respiratory mechanics rather than invasive ventilation.”
Strategies to prevent such injuries include patient selection to avoid high-risk limitations and continuous monitoring, as early recognition of P-SILI can prevent permanent lung damage. “Team education and protocol-driven care can help ensure timely adjustments to therapy and early identification of patients at risk.”
Challenges to more widespread implementation include clinician knowledge, availability of and access to equipment, and inconsistent protocol adoption. “Future research should focus on refining patient selection criteria, optimizing device settings and weaning strategies and integrating real-time monitoring tools to personalize noninvasive respiratory support,” the article adds.