Search Results (4,860)

Background: Cardiogenic shock is a life-threatening condition characterized by the failure of the heart to maintain adequate circulation, leading to multi-organ dysfunction. While it is most commonly associated with acute myocardial infarction or cardiomyopathies, cardiogenic shock can also arise in unusual settings, such as severe malnutrition in patients with anorexia nervosa, a psychiatric disorder characterized by extreme restriction of food intake. Methods: Here, we describe the management of three patients with anorexia nervosa and severe cardiogenic shock, who were treated in our cardiological intensive care unit between December 2022 and January 2025. Two patients were successfully resuscitated after experiencing cardiac arrest, and two required mechanical circulatory support, including Venoarterial Extracorporeal Membrane Oxygenation and microaxial flow pump. The patients presented with a range of complications including multi-organ failure and respiratory distress. Due to the fragile balance between intensive cardiac and nutritional management, as well as the comorbidity of chronic malnutrition, therapeutic decisions were made carefully, including cautious electrolyte management, targeted nutritional therapy, and the use of advanced circulatory support. Conclusion: The treatment approach and beneficious outcomes underline the necessity of a multidisciplinary strategy in managing these critically ill patients with complex, interwoven pathologies. Our experience suggests that early recognition of cardiogenic shock and timely intervention with mechanical circulatory support may significantly improve patient survival in this high-risk cohort. Careful management of nutritional therapy and supplementation of trace elements and vitamins is crucial. Full article

Oxygen (O₂) is vital for cellular development, function, proliferation, and repair, underscoring its critical role in organogenesis. Both hypoxia (reduced tissue O₂) and hyperoxia (excess tissue O₂), when prolonged, can trigger inflammation and oxidative stress, contributing to acute and long-term cardiopulmonary and neurodevelopmental morbidity. In sick neonates, immature defense mechanisms and coexisting morbidities demand nuanced and sometimes opposing strategies for O₂ saturation targets and therapeutic titration. Most current neonatal O₂ targeting guidelines are based on animal models or small clinical studies, resulting in recommendations with limited evidence. This narrative review aims to provide an updated overview of the physiological roles of O₂ in development, its delivery and consumption, approaches to O₂ saturation monitoring, and therapeutic targeting in neonates under both normal and pathological conditions. We also highlight key knowledge gaps and propose directions for future research on neonatal O₂ saturation targeting. Full article

Background/Objectives: In hospital settings, the wide variability of acute and complex chronic conditions—among both adult and pediatric patients—requires advanced approaches to detect early signs of clinical deterioration and the risk of transfer to the intensive care unit (ICU). Nursing diagnoses (NDs), standardized representations of patient responses to actual or potential health problems, reflect nursing complexity. However, most studies have focused on the total number of NDs rather than the individual role each diagnosis may play in relation to outcomes such as ICU transfer. This study aimed to identify and rank the specific NDs most strongly associated with ICU transfers in hospitalized adult and pediatric patients. Methods: A retrospective, monocentric observational study was conducted using electronic health records from an Italian tertiary hospital. The dataset included 42,735 patients (40,649 adults and 2086 pediatric), and sociodemographic, clinical, and nursing data were collected. A random forest model was applied to assess the predictive relevance (i.e., variable importance) of individual NDs in relation to ICU transfers. Results: Among adult patients, the NDs most strongly associated with ICU transfer were Physical mobility impairment, Injury risk, Skin integrity impairment risk, Acute pain, and Fall risk. In the pediatric population, Acute pain, Injury risk, Sleep pattern disturbance, Skin integrity impairment risk, and Airway clearance impairment emerged as the NDs most frequently linked to ICU transfer. The models showed good performance and generalizability, with stable out-of-bag and validation errors across iterations. Conclusions: A prioritized ranking of NDs appears to be associated with ICU transfers, suggesting their potential utility as early warning indicators of clinical deterioration. Patients presenting with high-risk diagnostic profiles should be prioritized for enhanced clinical surveillance and proactive intervention, as they may represent vulnerable populations. Full article

Background and Clinical Significance: Ventricular septal defect (VSD) is a rare but serious complication following myocardial infarction (MI) that can lead to cardiogenic shock and carries a high mortality rate. Acute mitral regurgitation (MR) is another severe complication of MI with additional risks of mortality. The optimal timing of surgical intervention for VSD with MR is still being debated, and delaying surgery in medically manageable patients has been associated with improved survival. However, managing these patients in the intensive care unit (ICU) presents unique challenges. Case Presentation: In this paper, we present the case of a 52-year-old male with comorbidities who developed post-MI VSD with severe MR and underwent successful delayed surgical repair and mitral valve replacement. Our aim is to highlight the clinical characteristics, diagnostic approach, and management strategies of this rare complication in the critical care setting. The patient presented in cardiogenic shock and acute pulmonary edema. After stabilization using an intra-aortic balloon pump, pre- and afterload reducing pharmacotherapy and non-invasive mechanical ventilation, a watchful waiting strategy was employed, and surgery was performed on day 21 after hospital admission. Surgery was performed under general anesthesia, and the patient did not develop any complications related to the intra-aortic balloon pump or novel organ dysfunction. Conclusions: This case highlights the importance of a multidisciplinary approach to managing post-MI VSD with MR and emphasizes the need for careful patient selection and timing of surgical intervention in the critical care setting. Clinicians should be aware of the potential benefits of delaying surgical intervention in medically manageable patients, while also considering the unique challenges of managing these patients in the ICU. Full article

Introduction: Among aortic diseases in children, congenital defects such as coarctation of the aorta (CoA), interrupted aortic arch (IAA), hypoplastic aortic arch (HAA), and hypoplastic left heart syndrome (HLHS) predominate. Tissue patches are applied in pediatric cardiovascular surgery for the repair of congenital aortic defects as a filling material to replenish missing tissue or as a substitute material for the complete reconstruction of the vascular wall along the course of the vessel. This retrospective single-center study aimed to present the safety and feasibility of extracellular matrix (ECM) biological scaffolds in pediatric aortic surgery. Patients and methods: There were 26 patients (17 newborns and nine children), who underwent surgical procedures in the Department of Pediatric Cardiac Surgery (Poznań, Poland) between 2023 and 2024. The patients’ population was divided into two subgroups according to the hemodynamic nature of the primary diagnosis of the congenital heart defect and the performed pediatric cardiovascular surgery. The first group included 18 (72%) patients after aortic arch repair for interrupted aortic arch and/or hypoplastic aortic arch, while the second group included seven (28%) patients after aortopulmonary anastomosis. In the first group, patches were used to reconstruct the aortic arch by forming an artificial arch with three separate patches sewn together, primarily addressing the hypoplastic or interrupted segments. In the second group, patches were applied to augment the anastomosis site between the pulmonary trunk and the aortic arch, specifically at the connection points in procedures, such as the Damus–Kaye–Stansel or Norwood procedures. The analysis was based on data acquired from the national cardiac surgery registry. Results: The overall mortality in the presented group was 15%. All procedures were performed using median sternotomy with a cardiopulmonary bypass. The cardiopulmonary bypass (CPB) and aortic cross-clamp (AoX) median times were 144 (107–176) and 53 (33–79) min, respectively. There were two (8%) cases performed in deep hypothermic circulatory arrest (DHCA). The median postoperative stay in the intensive care unit (ICU) was 284 (208–542) h. The median mechanical ventilation time was 226 (103–344) h, including 31% requiring prolonged mechanical ventilation support. Postoperative acute kidney failure requiring hemodiafiltration (HDF) was noticed in 12% of cases. Follow-up data, collected via routine transthoracic echocardiography (TTE) and clinical assessments over a median of 418 (242.3–596.3) days, showed no evidence of patch-related complications such as restenosis, aneurysmal dilation, or calcification in surviving patients. One patient required reintervention on the same day due to a significantly narrow ascending aorta, unrelated to patch failure. No histological data from explanted patches were available, as no patches were removed during the study period. The median (Q1–Q3) hospitalization time was 21 (16–43) days. Conclusions: ProxiCor^® biological patches derived from the extracellular matrix can be safely used in pediatric patients with congenital aortic arch disease. Long-term follow-up is necessary to confirm the durability and growth potential of these patches, particularly regarding their resistance to calcification and dilation. Full article

Introduction: Managing glycemic fluctuations in critically ill elderly patients with type 2 diabetes mellitus (T2DM) poses significant challenges. This case report presents a unique scenario in which increased intravenous glucose (Glc) infusion, together with insulin therapy, improved glycemic control and reduced insulin requirements during a septic episode. This finding adds to the scientific literature by suggesting that adequate Glc administration may enhance insulin sensitivity in critically ill T2DM patients. Case report: An 84-year-old female patient with T2DM, hypertension, and chronic renal failure was admitted to the intensive care unit with fever, nausea, loss of appetite, and profound weakness. Laboratory findings revealed severe hyperglycemia, electrolyte imbalances, and markedly elevated inflammatory markers, leading to the diagnosis of decompensated T2DM that was complicated by sepsis. The initial treatment consisted of continuous intravenous (IV) insulin, crystalloid infusions, and broad-spectrum antibiotics. Despite insulin therapy and the absence of nutritional intake, the patient experienced extreme fluctuations in their blood glucose levels, ranging from hyperglycemia to hypoglycemia. Due to persistent glycemic instability, IV Glc infusion was initiated alongside continuous insulin therapy. Paradoxically, increasing Glc infusion administration rate led to a reduction in the required insulin doses and stabilization of blood glucose levels below 10 mmol·L⁻¹. The patient’s C-peptide levels were initially elevated but subsequently decreased following Glc administration as well, suggesting a reduction in endogenous insulin secretion and therefore higher insulin sensitivity. The patient’s clinical condition improved, allowing for the transition to a subcutaneous insulin regime and the initiation of oral feeding. She was later transferred to a general medical ward and discharged without further complications. Conclusions: This case highlights the complex interplay between Glc and insulin in critically ill elderly patients with T2DM during sepsis. The main takeaway is that carefully managed Glc infusion, in conjunction with flexible insulin therapy, can enhance insulin sensitivity and stabilize blood glucose levels without causing further hyperglycemia. Frequent glycemia monitoring and adaptable glycemic management strategies are essential in the ICU to address rapid glycemic fluctuations in this patient population. Full article

Background: Allostatic load reflects the cumulative physiological effects of chronic and repeated stress on the body and is associated with dysregulation of multiple systems. This study aimed to examine the association between the allostatic load score (ALS) and the development of delirium in intensive care unit (ICU) patients. Method: The adult patients from the Medical Information Mart for Intensive Care (MIMIC-IV) database were screened and included in this study. Allostatic load was scored by hemoglobin A1c, high-density lipoprotein, total cholesterol, systolic blood pressure, diastolic blood pressure, body mass index, C-reactive protein, and serum albumin, and varied from 0 to 8. Restricted cubic spline and multivariate logistic regression were used to assess the relationship between ALS and delirium risk in the ICU. The threshold of the ALS was determined by the decision tree approach. A sensitivity analysis was also conducted. Results: A total of 656 patients were included in the study, and the incidence of delirium was 50.6% (n = 332). In a fully adjusted restricted cubic spline model, an increase in ALS was linearly positively correlated with the occurrence of delirium in the ICU (p-overall = 0.039, p-nonlinear = 0.506). The threshold for ALS was determined to be 3. ALS ≥ 3 was associated with increased delirium rates (p < 0.001), longer hospital stays (p < 0.001), and higher in-hospital mortality (p = 0.002). Subgroup analyses revealed no significant interactions (all p values for interactions > 0.05). Conclusions: Higher ALS was linearly associated with increased risk of ICU delirium. An ALS ≥ 3 identified patients with greater delirium incidence, longer hospital stays, and higher mortality. Full article

Objectives: Systemic inflammation, coagulopathy, and multiorgan dysfunction are common in critically ill patients and contribute significantly to mortality. Serum albumin and D-dimer are routinely used biomarkers that reflect nutritional status and coagulation activity, respectively. This study aimed to investigate the prognostic value of the albumin-to-D-dimer ratio (ADR) in predicting 30-day mortality among patients admitted to the intensive care unit (ICU) and undergoing mechanical ventilation. Methods: This retrospective cohort study included 162 adult patients who underwent invasive mechanical ventilation in the ICU of a tertiary care center between January 2021 and December 2023. Demographic data, comorbidities, and laboratory values—such as serum albumin, D-dimer, lactate, CRP, BUN, creatinine, INR, and platelet count—were recorded within the first 24 h of ICU admission. The albumin-to-D-dimer ratio (ADR) was calculated by dividing serum albumin (g/dL) by D-dimer (μg/mL). The patients were stratified into tertiles based on ADR values: low (<0.95), intermediate (0.95–1.45), and high (>1.45). The association between the ADR and 30-day mortality was analyzed using multivariate logistic regression and receiver operating characteristic (ROC) curve analysis. Results: Of the 162 patients included in the study, 61 (37.7%) died within 30 days. The patients who died had significantly lower ADR values at ICU admission compared to survivors (1.02 ± 0.43 vs. 1.56 ± 0.52, p < 0.001). In the multivariate logistic regression model, a lower ADR remained an independent predictor of 30-day mortality (OR: 0.39; 95% CI: 0.26–0.58; p < 0.001), even after adjusting for age, lactate, creatinine, INR, and other relevant clinical variables. ROC curve analysis demonstrated that the ADR had the highest discriminative performance among all the evaluated parameters, with an AUC of 0.802 (95% CI: 0.728–0.875; p < 0.001). The optimal cut-off value for the ADR was identified as <1.05, yielding a sensitivity of 78.7% and a specificity of 71.4% in predicting 30-day mortality. Conclusions: The ADR is independently associated with 30-day mortality in mechanically ventilated ICU patients and may serve as a useful early prognostic marker. However, given the retrospective, single-center nature of this study, these findings should be interpreted with caution. Further prospective, multicenter studies are needed to validate the clinical utility of the ADR. Full article

Introduction: Malnutrition is a recognized risk factor for unfavorable clinical outcomes and complications in cardiovascular and surgical patients. Nutritional status can be assessed with various methods, and the phase angle (PA) derived from bioelectrical impedance analysis is one of the most reliable parameters for that purpose. Methods: The aim of this narrative review was to present the available data regarding PA application in cardiac surgery. After careful analysis of PubMed and Scopus databases, 21 articles were included in the final analysis. Results: PA is a parameter that can be used for nutritional status assessment in a cardiac surgery environment. It is suggested that it is more accurate than other criteria in malnutrition identification in this group of patients. The available data shows its association with mortality, length of intensive care unit stay, and hospital stay. It can also predict adverse events such as blood transfusion or mechanical ventilation. Conclusions: The available data underscores the usefulness of PA in preoperative risk assessment and post-procedural monitoring. PA could be introduced in everyday clinical assessment in cardiac surgery. Full article

Background: Depression and anxiety are common in patients with chronic respiratory diseases (CRDs), but their prevalence in intensive care settings, particularly in low-resource regions, remains underexplored. Objective: To assess the prevalence and severity of depression and anxiety in patients with CRDs admitted to an intensive care unit (ICU) and identify associated factors. Methods: A cross-sectional study was conducted at Gulab Devi Teaching Hospital, Lahore, Pakistan. Adult patients with CRDs admitted to the ICU were assessed using the Hamilton Depression Rating Scale. Statistical analyses included Fisher’s exact test, Mann–Whitney/Kruskal–Wallis tests, and logistic regression. Results: Depression was highly prevalent across all CRD categories: 83%, 89%, 84%, and 93% in obstructive, restrictive, infectious, and other respiratory disease categories, and severe depression in 16%, 18%, 14%, and 37%, respectively. Anxiety symptoms were also widespread (77–100%), with no significant differences across disease groups. Depression was significantly associated with older age (p < 0.001, OR 1.08) and anxiety symptoms (p < 0.001, OR 47.07). Female gender was linked to anxiety (p = 0.034, OR 4.17). Conclusion: The high burden of depression and anxiety in ICU patients with CRDs underscores the need for routine psychiatric screening and integrated mental health care in critical-care settings. Full article

Background: Post-intensive care syndrome (PICS) affects over half of intensive care unit (ICU) survivors, impairing their long-term health and quality of life. Although the Post-Intensive Care Syndrome Questionnaire (PICSQ) was developed to measure PICS, validated cutoff values for screening are lacking. This study aimed to determine optimal cutoff values for each domain of the PICSQ. Methods: A total of 475 ICU survivors completed the PICSQ three months after discharge. Receiver operating characteristic (ROC) curve analyses were conducted to determine optimal cutoff values for each domain. The criterion tools included the Hospital Anxiety and Depression Scale, the Posttraumatic Diagnostic Scale, the Activities of Daily Living scale, and the Montreal Cognitive Assessment. Health-related quality of life and hospital readmission rates were compared between groups classified by the determined cutoffs. Results: The optimal cutoff values were ≥3 for mental, ≥7 for physical, and ≥2 for cognitive domains, with area under the curve (AUC) values of 0.83, 0.84, and 0.80, respectively. The participants scoring above these cutoffs had significantly lower quality of life and higher readmission rates. Conclusions: The determined cutoff values may support early screening of PICS in ICU survivors, enabling timely interventions to improve long-term outcomes. Further research is needed to validate these values in diverse populations. Full article

Background: Bile leakage remains a significant challenge following major liver resection, with potential for improvement depending on the transection technique used. In this study, we aimed to evaluate the effectiveness of our hybrid resection technique—utilizing both LigaSure and stapler devices—in reducing bile leakage after major liver resection compared to our conventional stapler-only technique. As a secondary aim, we compared overall morbidity, costs, and reimbursements. Method: Patients who underwent major hepatectomy without biliary reconstruction using either the hybrid or stapler technique between August 2014 and December 2021 were included in the study. Propensity score matching was performed using a one-to-two algorithm. Perioperative data, bile leakage rates, and cost and reimbursement information based on the diagnosis-related group (DRG) system were analyzed. Results: In total, data from 492 patients were evaluated (hybrid = 152; stapler = 340). After one-to-two propensity score matching, the operation time was significantly longer in the hybrid group (p = 0.005). A cost analysis showed no significant difference in total operative costs between the two techniques (p = 0.092). However, the hybrid group had a significantly lower rate of bile leakage (p = 0.002), as well as shorter intensive care unit (ICU) and overall hospital stays (p = 0.034 and p = 0.007, respectively). Consequently, ICU and ward costs were significantly lower in the hybrid group (p = 0.024 and p = 0.014, respectively) compared to the stapler group. The financial difference calculated as DRG reimbursement minus costs was two-fold higher in the hybrid group (p = 0.02). Conclusions: Although the hybrid technique resulted in a longer operating time, it proved superior to the stapler technique in reducing postoperative bile leakage and shortening ICU and hospital stays. Furthermore, the use of the hybrid technique was more cost efficient and resulted in a greater positive financial margin. Full article

Background: Classification trees (CTs) are widely used machine learning algorithms with growing applications in clinical research, especially for risk stratification. Their ability to generate interpretable decision rules makes them attractive to healthcare professionals. This review provides an accessible yet rigorous overview of CT methodology for clinicians, highlighting their utility through a case study addressing the “obesity paradox” in critically ill patients. Methods: We describe key methodological aspects of CTs, including model development, pruning, validation, and classification types (simple, ensemble, and hybrid). Using data from the ENPIC (Evaluation of Practical Nutrition Practices in the Critical Care Patient) study, which assessed artificial nutrition in ICU (intensive care unit) patients, we applied various CT approaches—CART (classification and regression trees), CHAID (chi-square automatic interaction detection), and XGBoost (extreme gradient boosting)—and compared them with logistic regression. SHAP (SHapley Additive exPlanation) values were used to interpret ensemble models. Results: CTs allowed for identification of optimal cut-off points in continuous variables and revealed complex, non-linear interactions among predictors. Although the obesity paradox was not confirmed in the full cohort, CTs uncovered a specific subgroup in which obesity was associated with reduced mortality. The ensemble model (XGBoost) achieved the best predictive performance (highest area under the ROC curve), though at the expense of interpretability. Conclusions: CTs are valuable tools in clinical epidemiology, complementing traditional models by uncovering hidden patterns and enhancing risk stratification. While ensemble models offer superior predictive accuracy, their complexity necessitates interpretability techniques such as SHAP. CT-based approaches can guide personalized medicine but require cautious interpretation and external validation. Full article

Pediatric Intensive Care Units (PICUs) provide specialized care for critically ill children. Developing and managing these units in South Asia remains challenging. Resource limitations and infrastructural disparities are leading to challenging conditions. Above all, nurses play a pivotal role in delivering quality critical care. Effective nursing practices can curb hospital-acquired infections (HAIs), ensure medication safety, and enable protocols such as the ICU Liberation Bundle. In South Asia, another challenge is the proper management of the nursing workforce. Nurse-to-patient ratios are highly disproportionate, contributing to nurse burnout. This review highlights the country-specific challenges and circumstances. There is no one-size-fits-all solution; effective strategies vary based on each country’s context. With context-specific solutions, nurses can bridge the gap between healthcare teams and families, ultimately improving patient outcomes. Full article

Candidemia is a significant cause of morbidity and mortality among critically ill patients. Early-onset candidemia is characterized by occurring within the first seven days after admission to the Intensive Care Unit and presents several important challenges regarding its management. Risk factors may vary among patients with early- and late-onset infection, while clinical manifestations are generally non-specific and covered by the underlying disease and co-morbidities. Diagnosis and appropriate therapy are frequently delayed, with a high risk of progression to invasive, deep-seated infections, leading to rapid clinical deterioration. Management strategies to optimize the approach for patients with early-onset candidemia include the use of both conventional and novel diagnostic techniques, the initiation of appropriate antifungal therapy, administration of an adequate dose, daily evaluation of clinical response, de-escalation treatment whenever possible, and early discontinuation. Incorporating an antifungal stewardship program in clinical practice is essential in order to achieve the best clinical outcomes. Based on a review and analysis of the available literature, this article provides a thorough update on the risk factors, clinical characteristics, diagnostic methods, and management of early-onset candidemia in adult critically ill patients. Full article