Noninvasive Respiratory Support,Steroid Nuances in Septic Shock,and Actionable Delirium Bundles

This noninferiority multicenter RCT across 33 Brazilian ICUs evaluated 1,766 patients randomized to High-Flow Nasal Oxygen (HFNO) or Noninvasive Ventilation (NIV) across 5 acute respiratory failure (ARF) groups: nonimmunocompromised hypoxemic, immunocompromised hypoxemic, COPD exacerbation with acidosis, cardiogenic pulmonary edema (ACPE), and COVID-19.

Overall, HFNO met noninferiority criteria for the primary endpoint of 7-day intubation or death (39% vs 38%). However, subgroup nuances were critical: enrollment was stopped for futility in immunocompromised patients due to higher primary event rates in HFNO (57.1% vs 36.4%), whereas nonimmunocompromised hypoxemic patients showed equal efficacy (32.5% vs 33.1%). Post-hoc non-hierarchical models raised caution regarding signal instability in COPD and ACPE.

This protocol outlines a pragmatic, double-blind, placebo-controlled international trial across 50 PICUs evaluating intravenous hydrocortisone (2 mg/kg loading, then 1 mg/kg q6h until vasoactive weaning or max 7 days) versus placebo in pediatric septic shock.

The trial addresses a major gap in critical care literature: while adult trials (ADRENAL, APROCCHSS) demonstrate faster shock reversal and reduced vasopressor duration with stress hydrocortisone, high-grade evidence in pediatric populations remains lacking. The primary outcome focuses on 28-day new or progressive multiple organ dysfunction syndrome (MODS) or mortality.

This narrative review synthesizes current evidence on ICU delirium, affecting approximately one-third of adult ICU admissions. The review emphasizes that routine pharmacological prophylaxis or treatment (including haloperidol and atypical antipsychotics) fails to shorten delirium duration or improve survival outcomes.

In contrast, non-pharmacological multicomponent strategies integrated into the ABCDEF bundle (Analgesia-first, Both SAT/SBT, Choice of sedation, Delirium monitoring/management, Early mobility, Family engagement) demonstrate robust efficacy in reducing delirium incidence, ICU length of stay, and long-term cognitive impairment.