Article 1
Time to Renal Replacement Therapy Initiation in Critically Ill Patients With Acute Kidney Injury: A Secondary Analysis of the Standard Versus Accelerated Initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) Trial. Jeong R, Bagshaw SM, Ghamarian E, Harvey A, Joannidis M, Kirkham B, McAuley D, Ostermann M, Quenot JP, Young PJ, Wald R. Crit Care Med. 2025 Apr 1;53(4):e897-e907.
This post hoc secondary analysis of a standard strategy cohort from an international randomized control trial (STARRT-AKI) sought to assess association between longer time to Renal Replacement Therapy initiation and clinical outcomes. Primary outcome investigators looked at was all-cause 90-day mortality, with secondary outcomes looking at RRT dependence, RRT-free days, hospital-free days at 90 days, LOS in the ICU and hospital LOS. There were a total of 1462 patients in the standard strategy group. Of these 903 (62%) underwent RRT. Results demonstrated lower mortality at 90 days (q 4 vs. 1: adjusted OR 0.63). This difference disappeared when examining time to RRT as continuous variable. Additionally, time to RRT initiation was not associated with RRT dependence, number of RRT-free days, or hospital free days at 90 days. The data did show that 388 patients survived to 90days with complete data, and those with longer delays to initiation of RRT had a higher probability of RRT dependence at 90 days (p=0.01). Longer delays to RRT were also associated with longer ICU LOS (quartile 4 vs 1: adjusted median of 8.3days) and longer hospital LOS (quartile 4 vs. 1: adjusted Median 12.7 days), but this effect disappeared when adjusted for death as a competing risk.
This study further highlights the safety of delayed RRT initiation in patients with acute kidney injury and no emergent indications for renal replacement therapy. It demonstrated no increased mortality, hospital or ICU LOS. However, one interesting point this study demonstrates is higher renal replacement therapy dependence at 90-days for patients initiated on RRT later in the course of their disease process. This may be secondary to cumulative effect of fluid accumulation, prolonged inflammatory response or chronic disease superimposed on acute kidney injury, which renders these patients more stable for longer period of time. This study makes several points that can be utilized in decision making to initiate RRT in acute kidney failure patients, and in the discussion with the patient and/or caregiver on the risks and benefits of initiating RRT.
Article 2
Use of extracorporeal membrane oxygenation in traumatic injuries with acute respiratory distress syndrome: A systematic review and meta-analysis. Akbarpoor F, Mokhtar J, Madera D, et al. J Trauma Acute Care Surg. 2026 Mar 1;100(3):501-508.
Is extracorporeal membrane oxygenation (ECMO) a useful organ support modality in traumatically injured patients with acute respiratory distress syndrome (ARDS)? The authors of this systematic review and meta-analysis address this question through a comprehensive review of the existing literature. They included all observational studies and randomized trials comparing ECMO with conventional mechanical ventilation in trauma patients with ARDS. The primary outcome was in-hospital mortality, with ventilator-associated pneumonia, duration of mechanical ventilation, hospital and ICU length of stay as secondary outcomes, and ECMO-related complications assessed as balancing outcomes. Only four nonrandomized studies met inclusion criteria, collectively reporting outcomes for 1,526 patients. Pooled analysis demonstrated a substantial mortality benefit associated with ECMO (odds ratio 0.29, 95% CI 0.14–0.62; p = 0.001). Most secondary and balancing outcomes did not reach statistical significance, with the exception of a longer ICU length of stay among ECMO-treated patients.
The principal contribution of this study is its specific focus on trauma patients with ARDS, a population that has been underrepresented or excluded in prior studies of ECMO for respiratory failure. Notably, these findings are consistent with (though perhaps more bullish than) the broader ECMO literature. Although the primary analysis of the EOLIA trial did not demonstrate a reduction in mortality with ECMO, a subsequent Bayesian reanalysis suggested a high probability of benefit. Importantly, while this systematic review supports a potential role for ECMO in trauma-associated ARDS, it does not define precise patient selection criteria. In contrast to the PROSEVA trial, which supported early prone positioning for hypoxemic respiratory failure, the present analysis appears to support ECMO primarily as a rescue therapy. The strongest mortality signal was observed in a study that deployed ECMO in patients with refractory PaO2/FiO2 ratios <100 despite maximal conventional mechanical ventilation, compared with historical controls. Using GRADE methodology, the strength of evidence was rated as high for mortality and ICU length of stay, but very low to moderate for all other outcomes. The practical takeaway is straightforward: in trauma patients with ARDS who are receiving optimal conventional mechanical ventilation and prone positioning, who continue to deteriorate, ECMO represents a reasonable, evidence-supported next step.
Note that EAST is currently conducting a full GRADE-based guideline exercise on the use of ECMO in trauma patients.
Article 3
Reassessing the timing of percutaneous gastrostomy tube placement: Too many too soon. Tatakis A, Wilson D, Holland H, et al. J Trauma Acute Care Surg. 2026 Jan 21.
This was a single-center retrospective cohort study at an urban Level 1 trauma center of patients undergoing non-elective, non-palliative PEG placement. The authors hypothesized that PEG placement carries risks associated with significant morbidity and that a proportion of PEG placements may ultimately be deemed unnecessary. The authors defined unnecessary placement as procedures performed for patients who became nutritionally independent at time of discharge, patients who were discharged to hospice, and patients who expired in the hospital. The primary outcome was rate of return to solid diet by mouth by time of discharge. Secondary outcomes included rate of return to nutritional independence, proportion of PEG placement for disposition purposes, duration of PEG tube requirement, and PEG complication rates.
Of 233 patients meeting inclusion criteria, 139 (59.7%) resumed a solid diet by mouth at time of discharge, and of those, 26 (18.7%) achieved nutritional independence at the time of discharge. Notably, trauma patients accounted for nearly half of the patients who became nutritionally independent at the time of discharge. Median time to nutritional independence was the shortest in trauma patients at 23 days (IQR 13-40 days], compared to 112 days, 54 days, 45 days, 32 days, and 29 days in oncologic, failure to thrive, neurologic, respiratory, and dysphagia groups, respectively. Of all patients, 19.7% were either nutritionally independent at discharge, transitioned to hospice care, or expired in the hospital. PEGs were placed to facilitate hospital disposition in 37.3% of cases. Approximately a quarter of the patients developed a PEG complication, most commonly tube dislodgement, followed by tube malfunction, and half of these required procedural care.
These findings may not reflect practice patterns and outcomes at other institutions. Nevertheless, this study suggests that not only were a significant proportion of PEGs placed for disposition purposes, many of them were ultimately unnecessary, and the complication rate was high. Together, these observations underscore the need for standardized, evidence-based protocols to guide practice, with placement decisions informed by prognostic models such as the PRESS calculator, which predicts the need for long-term enteral access after ischemic stroke.1 A counterbalance to strict risk-based decision making is existing evidence that patient-important factors such as comfort, convenience, and quality of life may favor PEG placement over nasogastric feeding.2 Acute care surgeons are well positioned to not only provide the procedural service of enteral access, but also to ensure that the decision-making around this important intervention is both evidence-informed and patient-centered.
