A passive leg raising (PLR) test is positive if the cardiac index (CI) increased by > 10%, but it requires a direct measurement of CI. On the oxygen saturation plethysmographic signal, the perfusion index (PI) is the ratio between the pulsatile and the non-pulsatile portions. We hypothesised that the changes in PI could predict a positive PLR test and thus preload responsiveness in a totally non-invasive way. In patients with acute circulatory failure, we measured PI (Radical-7) and CI (PiCCO2) before and during a PLR test and, if decided, before and after volume expansion (500-mL saline). Three patients were excluded because the plethysmography signal was absent and 3 other ones because it was unstable. Eventually, 72 patients were analysed. In 34 patients with a positive PLR test (increase in CI ≥ 10%), CI and PI increased during PLR by 21 ± 10% and 54 ± 53%, respectively. In the 38 patients with a negative PLR test, PI did not significantly change during PLR. In 26 patients in whom volume expansion was performed, CI and PI increased by 28 ± 14% and 53 ± 63%, respectively. The correlation between the PI and CI changes for all interventions was significant (r = 0.64, p < 0.001). During the PLR test, if PI increased by > 9%, a positive response of CI (≥ 10%) was diagnosed with a sensitivity of 91 (76–98%) and a specificity of 79 (63–90%) (area under the receiver operating characteristics curve 0.89 (0.80–0.95), p < 0.0001). An increase in PI during PLR by 9% accurately detects a positive response of the PLR test. ID RCB 2016-A00959-42. Registered 27 June 2016.

Purpose The European Society of Intensive Care Medicine (ESICM) Green Paper aims to address the challenge of environmental sustainability in intensive care and proposes actionable strategies for integrating sustainability into intensive care unit (ICU) stakeholder actions. Methods The ESICM Executive Committee appointed a task force of topic experts and ESICM committee representatives to develop the ESICM Green Paper. The task force convened biweekly from January to June 2024, identifying key domains for environmental sustainability and prioritizing actions. Drafts were iteratively refined and approved by the ESICM Executive Committee. Results Climate change will impact activities in intensive care in many ways, but also the impact of ICU activities on the environment is considerable; drivers for this include extensive resource use and waste generation in ICUs from energy consumption, use of disposable items, and advanced therapies for critically ill patients. The ESICM Green Paper outlines a structured approach for ICUs to reduce their environmental impact, emphasizing energy efficiency, waste reduction, and sustainable procurement. Furthermore, it endorses the need for awareness and education among healthcare professionals, integration of sustainability into research, and sustainable policies within scientific societies. Conclusions The ESICM Green Paper reviewed the relevance of climate change to intensive care and provided suggestions for clinical practice, research, education, and ESICM organizational domains. It underscores that reducing intensive care's ecological footprint can coexist with high-quality patient care. Promoting a resilient, responsible healthcare system is a joint responsibility of all ICU stakeholders.

Purpose To accommodate the unprecedented number of critically ill patients with pneumonia caused by coronavirus disease 2019 (COVID-19) expansion of the capacity of intensive care unit (ICU) to clinical areas not previously used for critical care was necessary. We describe the global burden of COVID-19 admissions and the clinical and organizational characteristics associated with outcomes in critically ill COVID-19 patients. Methods Multicenter, international, point prevalence study, including adult patients with SARS-CoV-2 infection confirmed by polymerase chain reaction (PCR) and a diagnosis of COVID-19 admitted to ICU between February 15th and May 15th, 2020. Results 4994 patients from 280 ICUs in 46 countries were included. Included ICUs increased their total capacity from 4931 to 7630 beds, deploying personnel from other areas. Overall, 1986 (39.8%) patients were admitted to surge capacity beds. Invasive ventilation at admission was present in 2325 (46.5%) patients and was required during ICU stay in 85.8% of patients. 60-day mortality was 33.9% (IQR across units: 20%–50%) and ICU mortality 32.7%. Older age, invasive mechanical ventilation, and acute kidney injury (AKI) were associated with increased mortality. These associations were also confirmed specifically in mechanically ventilated patients. Admission to surge capacity beds was not associated with mortality, even after controlling for other factors. Conclusions ICUs responded to the increase in COVID-19 patients by increasing bed availability and staff, admitting up to 40% of patients in surge capacity beds. Although mortality in this population was high, admission to a surge capacity bed was not associated with increased mortality. Older age, invasive mechanical ventilation, and AKI were identified as the strongest predictors of mortality.

Objectives: To compare the passive leg raising test ability to predict fluid responsiveness in patients with and without intra-abdominal hypertension. Design: Observational study. Setting: Medical ICU. Patients: Mechanically ventilated patients monitored with a PiCCO2 device (Pulsion Medical Systems, Feldkirchen, Germany) in whom fluid expansion was planned, with (intra-abdominal hypertension+) and without (intra-abdominal hypertension–) intra-abdominal hypertension, defined by an intra-abdominal pressure greater than or equal to 12 mm Hg (bladder pressure). Interventions: We measured the changes in cardiac index during passive leg raising and after volume expansion. The passive leg raising test was defined as positive if it increased cardiac index greater than or equal to 10%. Fluid responsiveness was defined by a fluid-induced increase in cardiac index greater than or equal to 15%. Measurements and Main Results: We included 60 patients, 30 without intra-abdominal hypertension (15 fluid responders and 15 fluid nonresponders) and 30 with intra-abdominal hypertension (21 fluid responders and nine fluid nonresponders). The intra-abdominal pressure at baseline was 4 ± 3 mm Hg in intra-abdominal hypertension– and 20 ± 6 mm Hg in intra-abdominal hypertension+ patients (p < 0.01). In intra-abdominal hypertension– patients with fluid responsiveness, cardiac index increased by 25% ± 19% during passive leg raising and by 35% ± 14% after volume expansion. The passive leg raising test was positive in 14 patients. The passive leg raising test was negative in all intra-abdominal hypertension– patients without fluid responsiveness. In intra-abdominal hypertension+ patients with fluid responsiveness, cardiac index increased by 10% ± 14% during passive leg raising (p = 0.01 vs intra-abdominal hypertension– patients) and by 32% ± 18% during volume expansion (p = 0.72 vs intra-abdominal hypertension– patients). Among these patients, the passive leg raising test was negative in 15 patients (false negatives) and positive in six patients (true positives). Among the nine intra-abdominal hypertension+ patients without fluid responsiveness, the passive leg raising test was negative in all but one patient. The area under the receiver operating characteristic curve of the passive leg raising test for detecting fluid responsiveness was 0.98 ± 0.02 (p < 0.001 vs 0.5) in intra-abdominal hypertension– patients and 0.60 ± 0.11 in intra-abdominal hypertension+ patients (p = 0.37 vs 0.5). Conclusions: Intra-abdominal hypertension is responsible for some false negatives to the passive leg raising test.

Objectives: Critical care ultrasonography has become established within ICUs as a diagnostic tool and to guide management strategies and practical procedures. Following an international consensus statement in 2011, various national professional societies and organizations have sought to develop and deliver training program. The aim of this review was to assess the similarities and differences among these postgraduate intensive care/critical care training program. Data Sources: A systematic review was performed in two steps. First, we searched medical databases and national societies’ websites for documents meeting predefined inclusion criteria. If not found, professionals related to critical care ultrasonography were contacted. Data Extraction: Data were extracted independently by two authors. Analyses were conducted on general training requirements as well as specific competencies defined in the documents. Data Synthesis: Eight national program from seven countries were identified from a total of 25 countries; all identified program have defined competencies for core critical care ultrasonography. Although there were common themes across these program, significant variations in training requirements and assessments existed, for example, number of scans required for echocardiography training ranged from 10 to 100. Furthermore, the specifics of each ultrasound module varied between program. Conclusions: Despite widespread and increasing use of ultrasound in ICUs, the majority of countries lacked a formal training program and clearly defined competencies. Even among the countries where these are available, there remains variability. There is a need to better define the competencies required in core critical care ultrasonography and standardize the assessment process.

Background: Although critical care ultrasound (CCUS) in the Intensive Care Unit has been increasing exponentially for diagnostic and therapeutic purposes, the lack of a uniform formal training structure and programme has posed the question of whether scans have been appropriately performed or reported, and whether there exists proper clinical governance to ensure a high standard of care. Methods: An online survey was sent to the representatives of various national intensive care societies via the European Society of Intensive Care Medicine CoBaTrICE committee. A comparison between 5 worldwide accreditation programmes was also made. Results: Twenty-seven out of 42 countries replied our survey. Five countries had a nationally accredited programme in ICM Echocardiography while six were in the process of developing one. Three countries had a CCUS-accredited programme. Most had local programmes. Transthoracic echocardiography, lung and vascular ultrasound were considered essential. Although CCUS training programmes should incorporate a combination of theoretical and practical teaching, it is not clear which is the best format. The main barriers to delivering CCUS training included a lack of formally agreed competencies, as well as a lack of trainers and time. There is also a lack of agreement between the five accreditation programmes. Conclusions: There is a need for a well-structured and competent CCUS training program. The use of ultrasound in critical care for diagnostic and therapeutic purposes has been increasing exponentially. Once the remit of radiologists and cardiologists, point-of-care ultrasound and focused echocardiography is becoming an increasingly routine instrument for all acute specialties including intensive care medicine, despite the lack of evidence that it improves patient mortality in the ICU setting. Background: Although critical care ultrasound (CCUS) in the Intensive Care Unit has been increasing exponentially for diagnostic and therapeutic purposes, the lack of a uniform formal training structure and programme has posed the question of whether scans have been appropriately performed or reported, and whether there exists proper clinical governance to ensure a high standard of care. Methods: An online survey was sent to the representatives of various national intensive care societies via the European Society of Intensive Care Medicine CoBaTrICE committee. A comparison between 5 worldwide accreditation programmes was also made. Results: Twenty-seven out of 42 countries replied our survey. Five countries had a nationally accredited programme in ICM Echocardiography while six were in the process of developing one. Three countries had a CCUS-accredited programme. Most had local programmes. Transthoracic echocardiography, lung and vascular ultrasound were considered essential. Although CCUS training programmes should incorporate a combination of theoretical and practical teaching, it is not clear which is the best format. The main barriers to delivering CCUS training included a lack of formally agreed competencies, as well as a lack of trainers and time. There is also a lack of agreement between the five accreditation programmes. Conclusions: There is a need for a well-structured and competent CCUS training program. The use of ultrasound in critical care for diagnostic and therapeutic purposes has been increasing exponentially. Once the remit of radiologists and cardiologists, point-of-care ultrasound and focused echocardiography is becoming an increasingly routine instrument for all acute specialties including intensive care medicine, despite the lack of evidence that it improves patient mortality in the ICU setting.