CANCARE RESEARCH
Explore previously published research highlights by topic, study type or publication date.
An automated research-discovery feed. Summaries are based on published abstracts and are not clinical recommendations.
Association Between Blood Pressure Response Index and Prognosis in Patients with Septic Shock Caused by Pneumonia.
Clinical takeaway BPRI may offer prognostic information in pneumonia-associated septic shock. These observational findings do not establish that targeting BPRI improves outcomes or that it should guide vasopressor management.
Summary & abstract
Study summary
A mixed retrospective and prospective cohort study examined the blood pressure response index (BPRI), defined as mean arterial pressure divided by vasoactive inotropic score, in pneumonia-associated shock. The retrospective cohort included 618 patients and the prospective cohort 65 patients. Higher BPRI was associated with lower mortality risk in the retrospective analysis (adjusted hazard ratio 0.843; 95% confidence interval 0.811–0.877). For 30-day mortality, BPRI discrimination was numerically higher than either component alone, with an area under the curve of 0.7404 (95% interval 0.7018–0.7790), and prospective findings were consistent.
Study limitation: The prospective cohort was small, and the abstract does not specify the BPRI measurement timing or the adjustment variables.
Published abstract
BackgroundNo noninvasive index exists to assess vasopressor responsiveness for maintaining blood pressure in severe pneumonia-induced shock. This study evaluated the association between the blood pressure response index (BPRI) and prognosis in such patients.MethodsA mixed retrospective and prospective cohort study analyzed clinical data from patients admitted to tertiary hospitals between January 2018 and January 2025. BPRI is the ratio between the mean arterial pressure and the vasoactive inotropic score. Cox regression analysis assessed the impact of BPRI on mortality risk, while Kaplan-Meier curves compared 30-day cumulative survival rates across BPRI tertiles. The receiver operating characteristic (ROC) curves evaluated BPRI's predictive accuracy for mortality. Restricted cubic spline (RCS) analysis explored potential nonlinear relationships between BPRI and mortality risk.ResultsThe retrospective cohort included 618 patients, with 332 (52.7%) fatalities. In the prospective cohort, 65 patients were enrolled, with 30 (46.2%) death. Cox regression analysis of the retrospective dataset indicated that higher BPRI values correlated with lower mortality risk (adjusted hazard ratio [HR]= 0.843, 95% confidence interval [CI] [0.811, 0.877]). The ROC analysis demonstrated that BPRI predicted 30-day mortality (area under the curve [AUC] = 0.7404, 95%=[0.7018,0.7790]) more accurately than the vasoactive inotropic score (AUC=0.7034, 95%CI = [0.6627,0.7440]) and mean arterial pressure (AUC=0.6638, 95%CI = [0.6201,0.7075]), consistent with prospective findings. The RCS analysis revealed a nonlinear relationship between BPRI and mortality risk, with a cutoff value of 9.05.ConclusionA lower BPRI was significantly associated with increased mortality risk, following a nonlinear pattern. BPRI demonstrated substantial predictive value for severe pneumonia-induced shock.
AI summary and clinical bottom line, with automated source checks. Consult the original paper before applying findings.
Effect of Vasopressin Initiation Threshold on Septic Shock Mortality: The VASSPR Cluster Crossover Randomized Strategy Trial.
Clinical takeaway A lower-threshold hospital strategy did not demonstrate reduced 28-day mortality in septic shock. These results address implementation strategies, not equivalence between individual vasopressin initiation thresholds.
Summary & abstract
Study summary
This pragmatic cluster-crossover randomized trial enrolled 3959 adults with septic shock across 13 hospitals, comparing hospital strategies recommending vasopressin initiation at lower versus higher doses of other vasopressors. At 28 days, mortality was 31.8% versus 33.0%; the adjusted risk difference was −0.4 percentage points (95% CI, −2.7 to 1.3), without a statistically significant reduction. Median kidney replacement therapy-free days were identical between strategies, with an adjusted marginal odds ratio of 1.01 (95% CI, 0.91 to 1.14). The intervention tested hospital-level recommendations rather than individually assigned vasopressin initiation.
Study limitation: Hospital-level recommendations produced overlapping initiation doses, limiting interpretation as a direct comparison of strictly separated individual treatment thresholds.
Published abstract
IMPORTANCE: The optimal vasopressor dose at which to initiate a second vasopressor in patients with septic shock is uncertain. OBJECTIVE: To compare the effects of hospital-level strategies initiating vasopressin infusion at a lower threshold vs a higher threshold on outcomes in patients with septic shock. DESIGN, SETTING, AND PARTICIPANTS: Cluster-randomized, cluster-crossover, pragmatic clinical strategy trial including adult patients receiving vasopressors for septic shock at 13 hospitals in Idaho and Utah from February 1, 2024, to July 31, 2025. The last day of follow-up for the primary outcome was February 17, 2026. INTERVENTION: Hospital-level implementation of septic shock management strategies recommending fixed-dose vasopressin initiation when the total dose of other vasopressors reached 0.1 µg/kg/min of norepinephrine or equivalent (lower-threshold strategy) or when the total dose of other vasopressors reached 0.4 µg/kg/min of norepinephrine or equivalent (higher-threshold strategy). Hospitals were randomized for the first month to an initial strategy (6 hospitals to the lower threshold vs 7 hospitals to the higher threshold) and then crossed over to the alternate strategy monthly thereafter. MAIN OUTCOMES AND MEASURES: The primary outcome of 28-day mortality and the key secondary outcome of kidney replacement therapy-free days through day 28 were analyzed using multivariable generalized linear mixed-effects models, accounting for trial site and baseline patient characteristics. RESULTS: There were 3959 unique patients with septic shock (median age, 68 [IQR, 57 to 77] years; 1903 [48%] were female). Of the patients more likely to experience differential management under the tested hospital-level vasopressin dose strategies (maximum vasopressor dose ≥0.07 µg/kg/min of norepinephrine or equivalent), 1034 of 1521 (68.0%) cared for under the lower-threshold strategy received vasopressin compared with 651 of 1526 (42.7%) cared for under the higher-threshold strategy. In the hospital-level strategy recommending a lower-dose threshold for vasopressin initiation, the maximum vasopressor dose received prior to vasopressin initiation was a median of 0.14 (IQR, 0.10 to 0.22) µg/kg/min of norepinephrine or equivalent vs 0.34 (IQR, 0.16 to 0.42) µg/kg/min of norepinephrine or equivalent in the hospital-level strategy recommending a higher-dose threshold for vasopressin initiation. Mortality at 28 days occurred in 628 of 1975 patients (31.8%) treated with the hospital-level strategy recommending initiation of vasopressin at a lower-dose threshold of other vasopressors vs 655 of 1984 patients (33.0%) treated with the higher-threshold strategy (adjusted marginal odds ratio, 0.98 [95% CI, 0.87 to 1.06], P = .62; adjusted risk difference, -0.4 [95% CI, -2.7 to 1.3] percentage points). Patients in both strategies for vasopressin initiation had a median of 29 (IQR, -1 to 29) kidney replacement therapy-free days (adjusted marginal odds ratio, 1.01 [95% CI, 0.91 to 1.14]). CONCLUSIONS AND RELEVANCE: In this large, pragmatic clinical trial comparing the effectiveness of 2 hospital-level strategies for second-line vasopressor management in septic shock, a strategy recommending initiation of vasopressin at a lower dose of other vasopressors did not reduce 28-day mortality compared with a strategy recommending vasopressin initiation at a higher dose of other vasopressors. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT06217562.
AI summary and clinical bottom line, with automated source checks. Consult the original paper before applying findings.
Hemodynamic trajectory phenotypes may modify associations between corticosteroid timing and outcomes in septic shock.
Clinical takeaway Haemodynamic trajectories may identify heterogeneity in associations between corticosteroid timing and septic-shock outcomes. These observational findings do not establish a benefit from delaying corticosteroids.
Summary & abstract
Study summary
This retrospective study examined corticosteroid timing in adults with vasopressor-treated septic shock across three ICU cohorts, identifying deteriorated and improved phenotypes from 168-hour haemodynamic trajectories. Early administration was defined as within six hours of sepsis onset, versus later administration. In the MIMIC-IV deteriorated phenotype, late corticosteroids were associated with lower 28-day mortality (HR 0.88 [0.78–0.98]) and shorter ventilation duration (HR 0.65 [0.58–0.73]). The mortality association was not consistently replicated in validation cohorts; the improved phenotype showed no consistent mortality or hospital length-of-stay association with later treatment.
Study limitation: Retrospective treatment comparisons remain vulnerable to confounding, and the mortality association was not consistently replicated across validation cohorts.
Published abstract
Corticosteroid trials in septic shock show conflicting results, with patient heterogeneity and treatment timing as likely contributors. We evaluated whether associations between corticosteroid timing and clinical outcomes differed by hemodynamic trajectory phenotype defined by dynamic time warping clustering of Blood Pressure-Vasopressor Index (BPRI) trajectories across three ICU cohorts. We conducted a retrospective cohort study using MIMIC-IV as the derivation cohort and eICU-CRD and PINES as validation cohorts. Adult patients with septic shock receiving vasopressors were included. Hemodynamic phenotypes were identified from 168-h BPRI trajectories. Corticosteroid timing was classified as early (≤ 6 h) or late (> 6 h) after sepsis onset. In MIMIC-IV, inverse probability of treatment weighting with cause-specific Cox regression was used to estimate associations between timing and 28-day mortality, hospital length of stay, and ventilation duration within each phenotype. Validation cohorts were analyzed using multivariable Cox regression, and cohort-specific estimates were summarized using random-effects meta-analysis with I2. Two phenotypes were identified in MIMIC-IV: Deteriorated (N=2,082, 38%), with declining hemodynamics and higher mortality, and Improved (N=3,361, 62%), with stable or rising trajectories. Similar trajectory patterns were observed in eICU-CRD and PINES. In the Deteriorated phenotype, late corticosteroids were associated with lower 28-day mortality in MIMIC-IV (HR 0.88 [0.78-0.98]) and shorter ventilation duration (HR 0.65 [0.58-0.73]) compared with early administration. The mortality association was not consistently replicated in validation cohorts, whereas the ventilation association was observed in PINES Deteriorated patients. In the Improved phenotype, late steroids showed no consistent mortality or hospital length-of-stay association. Exploratory hemodynamic response analysis showed a more favorable BPRI slope for late versus early steroids in the Deteriorated phenotype. Hemodynamic trajectory phenotypes identified clinically meaningful variation in the relationship between corticosteroid timing and outcomes in septic shock. In the Deteriorated phenotype, delayed corticosteroid initiation was associated with lower 28-day mortality and shorter recovery, whereas the Improved phenotype showed no mortality advantage from delayed treatment. These findings support incorporating dynamic hemodynamic trajectories into future studies of corticosteroid timing in septic shock.
AI summary and clinical bottom line, with automated source checks. Consult the original paper before applying findings.
Acute deoxygenation during M-TEER: a note of caution.
Clinical takeaway These findings suggest that right ventricular dysfunction and adverse atrial pressure relationships may help identify patients vulnerable to acute right-to-left shunting after M-TEER. They do not establish a validated prediction strategy.
Summary & abstract
Study summary
This retrospective study compared patients requiring emergency closure of an iatrogenic atrial septal defect after successful M-TEER with the remaining cohort. Among 444 consecutive patients, six (1.3%) required emergency closure for right-to-left shunting and acute deoxygenation. All six had severe tricuspid regurgitation, right ventricular dilatation and impaired right ventricular function; right atrial pressure exceeded left atrial pressure after M-TEER in five. Compared with controls, affected patients had lower tricuspid annular plane systolic excursion, fractional area change and right ventricular free wall strain magnitude. One patient developed cardiogenic shock.
Study limitation: The retrospective design and only six emergency closure events limit the reliability and generalizability of risk-factor associations.
Published abstract
AIMS: Right-to-left (R-L) shunting through an iatrogenic atrial septal defect (iASD) after mitral transcatheter edge-to-edge repair (M-TEER) is a rare but potentially life-threatening complication. We aimed to identify factors associated with clinically relevant R-L shunting requiring emergency iASD closure. METHODS AND RESULTS: We retrospectively analysed 444 consecutive patients undergoing successful M-TEER between 2017 and 2026. Clinical, echocardiographic, and invasive haemodynamic parameters were compared between patients requiring emergency iASD closure and the remaining cohort. Six patients (1.3%) required emergency iASD closure due to R-L shunting and acute deoxygenation. All presented with severe tricuspid regurgitation, RV dilatation, and impaired RV function. Following M-TEER, right atrial pressure exceeded left atrial pressure in five patients. Compared with controls, affected patients demonstrated reduced tricuspid annular plane systolic excursion (15 ± 2 vs. 19 ± 4 mm), fractional area change (FAC) (27 ± 5% vs. 43 ± 6%), and RV free wall strain (-13 ± 2% vs. -22 ± 5%). Echocardiography underestimated invasively measured systolic pulmonary artery pressure (25.8 vs. 40.3 mmHg; P = 0.035). Oxygen saturation decreased by 3-8%, with one patient developing cardiogenic shock. CONCLUSION: Severe tricuspid regurgitation, RV dysfunction, and elevated right atrial pressure may identify patients at risk for clinically relevant R-L shunting after M-TEER. Comprehensive RV assessment, including FAC and strain, combined with invasive hemodynamic evaluation, may improve risk stratification and facilitate timely iASD closure.
AI summary and clinical bottom line, with automated source checks. Consult the original paper before applying findings.
The Association of the Systemic Oxygen Delivery to Oxygen Consumption Ratio With Mortality, Heart Transplantation, and Mechanical Circulatory Support.
Clinical takeaway Continuous DO2/VO2 measurements may identify a higher-risk cardiac ICU phenotype, but the nonlinear association does not establish a clinically actionable threshold or a causal relationship.
Summary & abstract
Study summary
This retrospective cohort examined systemic oxygen delivery relative to consumption (DO2/VO2) in adults undergoing invasive haemodynamic assessment in medical and surgical cardiac intensive care units. Mortality showed a nonlinear association with DO2/VO2: relative to the median of 4.73, values around 2 were associated with the highest mortality likelihood. A prespecified cut-point of 5 showed no significant mortality association in Kaplan-Meier analysis. The ratio was also not significantly associated with mechanical circulatory support or heart transplantation; the abstract reported no numerical effect estimates or uncertainty intervals.
Study limitation: The retrospective design limits causal interpretation, and the abstract omits sample size, mortality follow-up duration, and numerical effect estimates.
Published abstract
OBJECTIVES: To identify if the delivery of oxygen over consumption of oxygen (DO2/VO2) ratio is significantly associated with clinical outcomes such as mortality, need for heart transplantation, or need for a mechanical circulatory support device. DESIGN: Retrospective cohort study. SETTING: Medical and surgical cardiac intensive care units of the Mayo Clinic. PARTICIPANTS: Adult patients (≥18 years old) admitted to the cardiothoracic surgical or cardiac intensive care units between January 2012 and December 2025 were included if they underwent invasive hemodynamic assessment with simultaneous arterial blood gas, mixed venous blood gas, hemoglobin, and mean arterial pressure. Patients were excluded if they had their venous oxygen saturations drawn from a central line or a peripherally inserted central catheter, as well as those admitted for sepsis/septic shock. INTERVENTIONS: No interventions were performed on patients. MEASUREMENTS AND MAIN RESULTS: DO2/VO2 demonstrated a nonlinear association with mortality. Using the median value of 4.73 as a reference point, patients with a DO2/VO2 value of ∼2 had the highest likelihood of mortality. Kaplan-Meier analysis using a prespecified cut-point of 5 did not demonstrate any significant relationship with mortality, likely because of the underlying nonlinear relationship. There was no significant association between DO2/VO2 ratio and the need for mechanical circulatory support or heart transplantation. CONCLUSIONS: DO₂/VO₂ is a marker of systemic oxygen balance that complements conventional hemodynamic indices. A categorical threshold of 5 did not show an association with clinical outcomes, but continuous analyses did suggest that a low DO₂/VO₂ may identify a high-risk phenotype.
AI summary and clinical bottom line, with automated source checks. Consult the original paper before applying findings.
Association of Preexisting Atrial Fibrillation or Flutter With 30-Day Outcomes After Septic Shock: A Propensity-Matched Federated Database Study.
Clinical takeaway Preexisting AF/flutter was associated with modestly higher mortality and greater organ-support use in septic shock. These findings support prognostic relevance, not a causal effect or treatment change.
Summary & abstract
Study summary
This federated database study compared adults with septic shock with versus without preexisting atrial fibrillation or flutter, matching 76,295 patients per group. Preexisting arrhythmia was associated with higher 30-day mortality (RR 1.07, 95% CI 1.06–1.09). Associations were also observed for renal replacement therapy (RR 1.30, 95% CI 1.25–1.35), invasive mechanical ventilation (RR 1.14, 95% CI 1.12–1.16), and vasopressor/inotrope use (RR 1.09, 95% CI 1.08–1.10). Cerebral infarction did not differ significantly (RR 1.11, 95% CI 1.00–1.24; P=0.054), which does not establish equivalent risk.
Study limitation: Propensity matching cannot exclude residual confounding, and this observational comparison does not establish causation.
Published abstract
Preexisting atrial fibrillation (AF) or atrial flutter may impair cardiovascular reserve during septic shock, potentially leading to worse clinical outcomes; however, its independent association with short-term outcomes remains uncertain. Using the TriNetX U.S. Collaborative Network, we identified adults with septic shock and compared patients with preexisting AF/flutter, documented at least 1 month before the index event, with those without prior AF/flutter. Clinical outcomes were compared after 1:1 propensity score matching for demographic characteristics, comorbidities, and baseline cardiovascular medication use. Outcomes included 30-day all-cause mortality, cerebral infarction, renal replacement therapy, invasive mechanical ventilation, acute-care utilization, and vasopressor/inotrope use. Effect estimates were reported as relative risks (RRs) with 95% confidence intervals. After propensity score matching, 76,295 patients were included in each cohort. Preexisting AF/flutter was associated with significantly higher risks of all-cause mortality (RR 1.07, 95% CI, 1.06-1.09; P<0.001), renal replacement therapy (RR 1.30, 95% CI, 1.25-1.35; P<0.001), invasive mechanical ventilation (RR 1.14, 95% CI, 1.12-1.16; P<0.001), acute-care utilization (RR 1.06, 95% CI, 1.05-1.06; P<0.001), and vasopressor/inotrope use (RR 1.09, 95% CI, 1.08-1.10; P<0.001). There was no significant difference in cerebral infarction (RR 1.11, 95% CI, 1.00-1.24; P=0.054). Among patients with septic shock, preexisting AF/flutter was associated with higher mortality and greater use of organ-supportive therapies, including renal replacement therapy, invasive mechanical ventilation, and vasopressor/inotrope use, but not with a significant increase in cerebral infarction. Preexisting AF/flutter may serve as an important prognostic marker for early risk stratification in septic shock.
AI summary and clinical bottom line, with automated source checks. Consult the original paper before applying findings.
Efficacy and Safety of Etomidate Versus Ketamine for Endotracheal Intubation in Critically Ill Patients: A Systematic Review and Meta-Analysis.
Clinical takeaway The pooled trials did not demonstrate a mortality difference between induction agents. Uncertainty around cardiac arrest and vasopressor estimates precludes interpreting these findings as equivalence.
Summary & abstract
Study summary
This systematic review pooled seven randomized trials involving 5234 critically ill adults undergoing emergency intubation with etomidate or ketamine. Etomidate versus ketamine showed no statistically significant difference in 28-day mortality (RR 1.01; 95% CI 0.93-1.10) or cardiac arrest (RR 0.91; 95% CI 0.62-1.34). Failed intubation (RR 1.09; 95% CI 0.68-1.76) and vasopressor requirement (RR 1.27; 95% CI 0.94-1.72) also did not differ significantly. Sensitivity analyses suggested possible haemodynamic differences, with relative cardiovascular stability for etomidate in some analyses, but these findings require cautious interpretation.
Study limitation: The abstract provides no cardiac ICU-specific subgroup results, limiting assessment of applicability to patients with cardiovascular critical illness.
Published abstract
Rapid sequence intubation (RSI) is a commonly used technique for critically ill patients requiring emergency intubation, and the choice of induction agent is crucial for minimizing peri-intubation morbidity and maintaining hemodynamic stability. The most commonly used induction agents are etomidate and ketamine, although controversy remains about their effectiveness and safety. Therefore, this systematic review and meta-analysis compared the efficacy and safety of etomidate versus ketamine for endotracheal intubation in critically ill patients. Randomized controlled trials (RCTs) published between 2000 and May 2026 were systematically searched in PubMed, The Cochrane Library, and ScienceDirect. The included studies compared etomidate with ketamine for emergency endotracheal intubation in critically ill adults. We analyzed data with RevMan 5.4 and Mantel-Haenszel random-effects models and calculated risk ratios (RRs) with 95% confidence intervals (CIs). Seven RCTs involving 5234 patients were included in the final analysis. No significant difference was observed between etomidate and ketamine regarding 28-day mortality (RR 1.01; 95% confidence interval (CI) 0.93-1.10; p=0.84), cardiac arrest (RR 0.91; 95% CI 0.62-1.34; p = 0.64), failed intubation (RR 1.09; 95% CI 0.68-1.76; p=0.71), or vasopressor requirement (RR 1.27; 95% CI 0.94-1.72; p=0.13). Sensitivity analyses suggested possible hemodynamic differences between the two agents, which should be interpreted cautiously, and etomidate was relatively cardiovascularly stable in some analyses. Overall, etomidate and ketamine showed similar efficacy and safety for endotracheal intubation in critically ill patients. No statistically significant differences were observed between the two agents in mortality, cardiac arrest, failed intubation, or vasopressor use. Thus, clinicians should choose the induction agent on a case-by-case basis, based on patient, hemodynamic, and clinician-specific factors. Randomized trials in selected critically ill patient populations should be conducted on a larger scale.
AI summary and clinical bottom line, with automated source checks. Consult the original paper before applying findings.