Sepsis is a heterogeneous syndrome. This study aimed to identify new sepsis sub-phenotypes using plasma cortisol trajectory. This retrospective study included patients with sepsis admitted to the intensive care unit of Zhongshan Hospital Fudan University between March 2020 and July 2022. A group-based cortisol trajectory model was used to classify septic patients into different sub-phenotypes. The clinical characteristics, biomarkers, and outcomes were compared between sub-phenotypes. A total of 258 patients with sepsis were included, of whom 186 were male. Patients were divided into two trajectory groups: the lower-cortisol group (n = 217) exhibited consistently low and slowly declining cortisol levels, while the higher-cortisol group (n = 41) showed relatively higher levels in comparison. The 28-day mortality (65.9% vs.16.1%, P < 0.001) and 90-day mortality (65.9% vs. 19.8%, P < 0.001) of the higher-cortisol group were significantly higher than the lower-cortisol group. Multivariable Cox regression analysis showed that the trajectory sub-phenotype (HR = 5.292; 95% CI 2.218–12.626; P < 0.001), APACHE II (HR = 1.109; 95% CI 1.030–1.193; P = 0.006), SOFA (HR = 1.161; 95% CI 1.045–1.291; P = 0.006), and IL-1β (HR = 1.001; 95% CI 1.000–1.002; P = 0.007) were independent risk factors for 28-day mortality. Besides, the trajectory sub-phenotype (HR = 4.571; 95% CI 1.980–10.551; P < 0.001), APACHE II (HR = 1.108; 95% CI 1.043–1.177; P = 0.001), SOFA (HR = 1.270; 95% CI 1.130–1.428; P < 0.001), and IL-1β (HR = 1.001; 95% CI 1.000–1.001; P = 0.015) were also independent risk factors for 90-day mortality. This study identified two novel cortisol trajectory sub-phenotypes in patients with sepsis. The trajectories were associated with mortality, providing new insights into sepsis classification.

Ventilator-associated pneumonia (VAP) is a major cause of morbidity in critically ill patients, and the SARS-CoV-2 infection has influenced the lung microbiome. This study aimed to examine the lower respiratory tract microbiome in VAP patients during different phases of the Shanghai COVID-19 epidemic. A total of 175 patients were included and divided into pre-epidemic (Pre), during-epidemic (Dur), and post-epidemic (Post) groups for analysis. Bronchoalveolar lavage fluid and serum were analyzed using next-generation sequencing. The intensive care unit (ICU) mortality rates were 48.3% (Pre group), 60.3% (Dur group), and 28.8% (Post group). Cytokine levels were lower in the Post group compared to the Pre group. Acinetobacter , Candida , and Herpes Simplex Virus 1 ( HSV-1 ) were the most frequently detected organisms. The prevalence of Klebsiella pneumoniae , Enterococcus faecium , Aspergillus fumigatus , and HSV-1 was higher in the Dur group. α-Diversity of bacteria was significantly lower in the Dur group ( P < 0.05), indicating reduced microbiome diversity. Multivariable Cox regression analysis identified APACHE II score (hazard ratio [HR] = 1.04, P = 0.029) and maximum bacterial load (HR = 1.67, P = 0.046) as independent risk factors for ICU mortality. This study highlights changes in microbiome composition across epidemic phases, which may inform treatment strategies. IMPORTANCE: With the development of next-generation sequencing technology, it is increasingly being applied in clinical practice, especially in evaluating the prognosis of severe infections and co-infections. This study characterized the composition of microorganisms in the lower respiratory tract of ventilator-associated pneumonia (VAP) patients across three phases of the COVID-19 epidemic. Our study emphasizes that the relative abundance of bacteria, fungi, and viruses in bronchoalveolar lavage fluid of VAP patients may vary with the progression of the local epidemic and host immune status. These findings provide a mechanistic basis for optimizing targeted therapies in VAP management during infectious disease outbreaks.

Low-flow extracorporeal carbon dioxide removal (ECCO ₂ R) may be useful when severe hypercapnia limits ultra-protective ventilation but full venovenous extracorporeal membrane oxygenation (VV-ECMO) is not pursued. We describe a 68 year old man with metastatic lung adenocarcinoma who developed amivantamab-associated immune-related interstitial lung disease complicated by acute respiratory distress syndrome (ARDS) and active airway hemorrhage. After endotracheal intubation, the dominant physiologic problem was hypercapnic acidosis (pH 7.12; PaCO ₂ 83.4 mm Hg) with very poor respiratory system compliance, whereas oxygenation impairment was moderate (PaO ₂ /FiO ₂ 160 mm Hg). Because of terminal malignancy and the burden of large-bore cannulation, VV-ECMO was not pursued. Electrical impedance tomography showed no benefit from prone positioning. A hybrid strategy was then initiated: inhaled nitric oxide to improve ventilation-perfusion (V/Q) matching and ECCO ₂ R to control carbon dioxide clearance. Within 2 hours, PaCO ₂ fell to 60.7 mm Hg and pH rose to 7.32; oxygenation also improved. The circuit remained functional for 13 days without recurrent airway bleeding or documented circuit thrombosis. This case illustrates the feasibility of concurrently applying inhaled nitric oxide and low-flow ECCO ₂ R as a physiology-guided, low-intensity rescue approach in a highly selected patient when VV-ECMO was not pursued.

Background Currently, there is no formal diagnostic criterion for sepsis-induced cardiomyopathy (SICM). The classic approach has been to use left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) to define SICM. In this regard, tissue motion annular displacement (TMAD) is a novel speckle tracking indicator to quickly assess LV longitudinal systolic function. This study aimed to evaluate the feasibility and application value of TMAD in the diagnosis of SICM in septic patients. Methods We conducted a single-center retrospective observational study in sepsis or septic shock patients who underwent echocardiography examination within the first 24h after admission. Basic clinical information and conventional echocardiographic data were collected. Based on speckle tracking echocardiography (STE), GLS and TMAD were respectively performed offline. The correlations between TMAD and other LV systolic function parameters, as well as the diagnostic value of TMAD for SICM, were assessed. Data of 28d and in-hospital mortality were compared between SICM and non-SICM patients. Results A total of 143 patients were enrolled in this study. The incidence of SICM according to GLS or TMAD criteria was significantly higher than that according to LVEF criteria (32.9% vs. 18.2%, p = 0.006; 38.5% vs. 18.2%, p < 0.001). The 28d and in-hospital mortality of SICM patients were significantly higher than the non-SICM patients according to any of the diagnostic criteria (all p < 0.05). Significant correlations between TMAD and other LV systolic function echocardiographic parameters, including LVEF, GLS, mitral annular plane systolic excursion (MAPSE), and maximal lateral systolic mitral annular tissue velocity (MA Smax), were detected (all p < 0.001). According to the AUROC value, TMADMid had an excellent diagnostic value for SICM (AUROC > 0.9). Compared with LVEF and GLS, TMAD had the highest intra-observer and inter-observer reliability. The mean time for off-line analyses with TMAD was significantly shorter than that with LVEF or GLS (p < 0.05). Conclusion STE-based TMAD is a feasible, reliable, and time-saving option to assess the LV systolic function. Overall, this approach shows an excellent diagnostic value for SICM in septic patients.

Postpartum pulmonary arterial hypertension (PAH) complicated with hereditary hemorrhagic telangiectasia (HHT) is a rare condition. Diagnosing and treating PAH in patients with HHT can be challenging. To the best of our knowledge, no previous reports have investigated the efficacy of pulmonary vasodilators in improving hemodynamics in postpartum patients with this disease. In this paper, we report a postpartum case of HHT combined with PAH, pre senting with worsening dyspnea. Genetic testing revealed that the patient carried a heterozygous variant of activin receptor-like kinase 1. The patient received various treatments, including diuretics, anticoagulants, sildenafil, macitentan, inhalation of nitric oxide, and iloprost. Changes in PaO₂/FiO₂, pulmonary artery systolic pressure as assessed by echocardiography, and N-terminus pro-brain natriuretic peptide levels suggested that, except for iloprost inhalation, the other treatments appeared to have limited efficacy. To our knowledge, this is the first report on efficacy of pulmonary vasodilators in postpartum patients with HHT and PAH.