Randomised controlled trials (RCTs) have reshaped intensive care medicine (ICM), a discipline defined by acute, interacting organ failures, time-sensitive decisions, biological uncertainty, and heterogeneous recovery trajectories. Many interventions supported by strong physiological rationale failed to improve patient-centred outcomes, whereas durable advances often emerged from optimisation of supportive care, avoidance of iatrogenic harm, and reassessment of established practices. We conducted an interpretive historical review of landmark multicentre RCTs in adult ICM from the early 1990s onwards. PubMed searches, reference lists from major trials and reviews, and international guidelines were used to identify trials with conceptual influence on practice, guidelines, physiological reasoning, therapeutic strategy, research priorities, de-implementation, or outcome framing. Evidence was organised into overlapping paradigms rather than rigid chronological periods. Across haemodynamic support, mechanical ventilation, renal replacement therapy, antimicrobial treatment, nutrition, glucose control, transfusion, and sedation, landmark RCTs describe more than therapeutic expansion. Early biological and haemodynamic trials exposed the limits of reductionist strategies in syndromic critical illness. Protocol-driven approaches improved timeliness and consistency, but later pragmatic trials showed that rigid targets and invasive algorithms often added little once high-quality usual care was established. More recent trials challenge the assumption that greater intervention intensity improves outcomes, emphasising timing, disease phase, baseline risk, heterogeneity, patient selection, and treatment-related harm. Modern ICM RCTs have clarified not only what works, but what can be reduced, delayed, avoided, or applied selectively. Future progress requires biologically informed, context-sensitive trials focussed on meaningful survival, recovery, and long-term function.
Pediatric intensive care units (PICUs) are well developed in Western countries and have been linked to improved survival. However, evidence comparing the outcomes between PICUs and general intensive care units (GICUs) remains inconsistent. In Japan, limited PICU capacity raises concerns that many children receive critical care in GICUs. This study compared the clinical outcomes between these settings using a national inpatient database and propensity score overlap weighting analyses. We conducted a retrospective cohort study using a national Japanese inpatient database from July 2010 to March 2022. We included mechanically ventilated children aged ≤14 years admitted to ICUs and compared patient characteristics between those treated in PICUs and GICUs. In-hospital mortality was evaluated using overlap weighting analyses. Of the 48,106 eligible patients, 36% received care in PICUs. After overlap weighting analyses, PICU care was associated with a significantly lower in-hospital mortality than GICU care (mean 2.73% vs. 3.42%; odds ratio, 0.79; 95% CI, 0.69-0.91; p = 0.001). PICU care was associated with longer overall hospital stays (mean 22.74 vs. 22.13 days; difference, +0.61 days; 95% CI, 0.30-0.93; p < 0.001) and longer ICU stays (mean 6.37 vs. 5.42 days; difference, +0.95 days; 95% CI, 0.82-1.09; p < 0.001). Most mechanically ventilated children in Japanese ICUs were treated in GICUs. Pediatric patient care in GICUs was associated with higher mortality relative to that in PICUs, underscoring the need for further centralization.
The management of hemodynamic instability in critically ill pediatric patients represents one of the most challenging aspects of intensive care medicine. The appropriate selection, timing, and titration of fluid therapy, inotropic and vasoactive agents can significantly impact patient outcomes, making the development and implementation of standardized protocols an essential aspect of quality care. This prospective observational study was carried out in the pediatric intensive care unit (PICU) among children aged 1 month to 14 years admitted to the PICU and requiring inotropic agents, after approval from the institutional scientific and ethics committee. A comprehensive evaluation of each enrolled patient was done and documented in a standardized case record form. Demographic and clinical details, including history, comorbidities, examination findings, diagnosis, type of shock, and laboratory parameters were noted. Details of inotropic agents used in each individual patient were documented. Response to therapy and outcome measures such as duration of inotropic support, need for escalation to multiple agents, time to achieve hemodynamic stability, success of weaning attempts, length of PICU stay, mechanical ventilation requirements, mortality, presence of multiorgan dysfunction, and use of steroids were noted and analyzed statistically. A total of 100 children (aged 1 month to 14 years) admitted to the PICU and requiring inotropic support were enrolled. Infants (<1 year) (35%) constituted the largest proportion of the study population, followed by children aged 1-5 years (33%). Respiratory symptoms with fever were the most common presenting complaints (28%), followed by gastrointestinal manifestations (24%). Comorbidities were present in 38% of patients, with cardiac conditions being the most prevalent. Hypovolemic shock was the most common type observed (44%), followed by septic shock (41%) and cardiogenic shock (18%). Fluid resuscitation practices in this study were consistent with international recommendations, with most patients receiving one or two boluses. Adrenaline was the most commonly used first-line inotrope (63%), although noradrenaline was preferentially used in septic shock and adrenaline in cardiogenic shock. More than half of the patients (56%) required escalation to a second inotrope. The use of complex combination therapy was significantly associated with mortality (P < 0.001); among nonsurvivors, 62.5% received combination therapy, compared with only 19.1% of survivors. In septic shock, early initiation and timely escalation of inotropic therapy were associated with improved hemodynamic stabilization. Mechanical ventilation was required in 59% of patients, and multiorgan dysfunction syndrome (MODS) was observed in 21%. The duration of PICU stay was influenced by the number of inotropes required, with prolonged stays associated with higher inotropic support. De-escalation of inotropic support was guided by clinical improvement and hemodynamic stability. Steroids were used selectively in 22% of patients. The overall mortality rate was 32%. Key predictors of adverse outcomes identified in this study included the requirement for multiple inotropes, the need for mechanical ventilation, and the presence of MODS. Protocol-based management of pediatric shock has been shown to improve outcomes. The findings of this study reinforce the importance of early recognition, timely intervention, and individualized, protocol-driven management in improving outcomes in pediatric shock. Résumé Contexte:La prise en charge de l’instabilité hémodynamique chez les enfants gravement malades représente l’un des plus grands défis de la médecine de soins intensifs. Le choix approprié, le moment d’instauration et l’ajustement de la fluidothérapie, ainsi que des agents inotropes et vasoactifs, peuvent avoir un impact significatif sur le pronostic des patients. Par conséquent, l’élaboration et la mise en œuvre de protocoles standardisés constituent un élément essentiel d’une prise en charge de qualité.Matériels et méthodes:Cette étude prospective observationnelle a été réalisée dans l’unité de soins intensifs pédiatriques (USIP) auprès d’enfants âgés de 1 mois à 14 ans, admis en USIP et nécessitant un traitement par agents inotropes, après approbation par le comité scientifique et le comité d’éthique de l’institution. Une évaluation complète de chaque patient inclus a été effectuée et consignée dans une fiche d’observation standardisée. Les données démographiques et cliniques, notamment les antécédents, les comorbidités, les résultats de l’examen clinique, le diagnostic, le type de choc et les paramètres biologiques, ont été recueillies. Les caractéristiques des agents inotropes administrés à chaque patient ont également été documentées. La réponse au traitement et les critères de jugement, notamment la durée du soutien inotrope, le recours à une escalade thérapeutique vers plusieurs agents, le délai d’obtention d’une stabilité hémodynamique, le succès du sevrage des inotropes, la durée de séjour en USIP, le recours à la ventilation mécanique, la mortalité, la présence d’un syndrome de défaillance multiviscérale (SDMV) et l’utilisation de corticostéroïdes, ont été analysés statistiquement.Résultats:Au total, 100 enfants âgés de 1 mois à 14 ans, admis en USIP et nécessitant un soutien inotrope, ont été inclus. Les nourrissons (<1 an) représentaient la plus grande proportion de la population étudiée (35 %), suivis des enfants âgés de 1 à 5 ans (33 %). Les symptômes respiratoires associés à la fièvre constituaient le principal motif de consultation (28 %), suivis des manifestations gastro-intestinales (24 %). Des comorbidités étaient présentes chez 38 % des patients, les cardiopathies étant les plus fréquentes. Le choc hypovolémique était le type de choc le plus courant (44 %), suivi du choc septique (41 %) et du choc cardiogénique (18 %). Les pratiques de remplissage vasculaire observées dans cette étude étaient conformes aux recommandations internationales, la majorité des patients ayant reçu un ou deux bolus de liquides. L’adrénaline était l’inotrope de première intention le plus utilisé (63 %), tandis que la noradrénaline était privilégiée dans le choc septique et l’adrénaline dans le choc cardiogénique. Plus de la moitié des patients (56 %) ont nécessité l’ajout d’un second agent inotrope. L’utilisation d’une association complexe d’agents vasoactifs était significativement associée à la mortalité (P < 0,001) ; parmi les patients décédés, 62,5 % avaient reçu une thérapie combinée, contre seulement 19,1 % des survivants. Dans le choc septique, l’instauration précoce et l’escalade rapide du traitement inotrope étaient associées à une meilleure stabilisation hémodynamique. Une ventilation mécanique a été nécessaire chez 59 % des patients et un syndrome de défaillance multiviscérale a été observé chez 21 %. La durée du séjour en USIP était influencée par le nombre d’inotropes administrés, les séjours prolongés étant associés à un recours accru au soutien inotrope. La diminution progressive du traitement inotrope était guidée par l’amélioration clinique et la stabilité hémodynamique. Des corticostéroïdes ont été utilisés de manière sélective chez 22 % des patients. Le taux global de mortalité était de 32 %. Les principaux facteurs prédictifs d’une évolution défavorable identifiés dans cette étude étaient la nécessité d’utiliser plusieurs agents inotropes, le recours à la ventilation mécanique et la présence d’un syndrome de défaillance multiviscérale.Conclusions:La prise en charge du choc pédiatrique fondée sur des protocoles améliore les résultats cliniques. Les résultats de cette étude soulignent l’importance d’une reconnaissance précoce, d’une intervention rapide et d’une prise en charge individualisée, guidée par des protocoles, afin d’améliorer le pronostic des enfants présentant un état de choc.
To analyse patient admission patterns, clinical outcomes, and organisational workload in a medical intensive care unit (ICU), with emphasis on early mortality and post-pandemic changes in healthcare demand. This retrospective, observational, single-centre cohort study included all adult patients admitted to the medical ICU of the Clinic for Internal Medicine at the University Clinical Centre Tuzla between January 1, 2018, and December 31, 2025. Aggregated data were obtained from the hospital information system and internal ICU records. Analysed variables included annual admission volume, admission sources, discharge outcomes, in-hospital and early mortality (within 24-72 hours after ICU admission), estimated length of stay, invasive procedures, and patient age. Temporal trends were assessed across pre-pandemic (2018-2019), pandemic (2020-2021), and post-pandemic (2022-2025) periods. A total of 9,342 ICU hospitalisations were analysed. Admissions remained relatively stable through 2020, declined in 2021, reached their lowest level in 2022, and then increased markedly from 2023 onward. Admissions per bed rose from 67.5 in 2022 to 108.6 in 2025, while the estimated mean ICU length of stay decreased from 5.4 to 3.4 days. Overall, in-hospital mortality was approximately 22%, with 75-80% of deaths occurring between 24 and 72 hours from admission. The patient population was predominantly elderly, with a mean age of approximately 70 years. Medical ICU services operated under increasing organisational strain, reflected by rising admission volume, higher admissions per bed, and reduced estimated length of stay despite fixed bed capacity. Persistently high early mortality remained a prominent feature of this population.
Major abdominal surgery is associated with a high incidence of postoperative complications, morbidity, and mortality. The Systemic Immune-Inflammation Index (SII), calculated from neutrophil, platelet, and lymphocyte counts, reflects both inflammatory and immune status and has been shown to predict outcomes in various diseases. This study aimed to retrospectively evaluate the outcomes of patients admitted to the intensive care unit (ICU) after urgent or elective major abdominal surgery and to investigate the association between postoperative SII and ICU mortality. We retrospectively analyzed patients admitted to the surgical ICU after major abdominal surgery between November 2022 and November 2023. Patients who died within the first 24 hours of ICU admission, were admitted to the ICU for less than 48 hours, and were younger than 18 years were excluded. During the study period, 360 patients were admitted to the surgical ICU, of whom 102 underwent major abdominal surgery. One patient was excluded because of death within the first 24 hours of ICU admission, leaving 101 patients for analysis. Fifty-nine patients (58.4%) were women, and the mean age was 70.1±15.2 years. Urgent abdominal surgery was performed in 42 patients (41.6%). ICU mortality was higher among patients who underwent urgent surgery (23.8%) than among those who underwent elective surgery (5.1%) (p=0.013). Receiver operating characteristic (ROC) curve analysis identified a postoperative SII cutoff value of 998.26. A low postoperative SII was independently associated with mortality after major abdominal surgery, with a sensitivity of 82.9% and a specificity of 69.2% (95% confidence interval: 0.0579-0.913, p=0.004). Postoperative SII may be a useful prognostic marker for predicting clinical outcomes and mortality in patients undergoing major abdominal surgery.
Intensive care unit (ICU) nurses are chronically exposed to patient suffering, death, and morally complex decisions, placing them at elevated risk of empathy fatigue. China currently lacks a psychometrically sound instrument developed specifically to capture empathy fatigue within the ICU specialty context. This study aimed to cross-culturally adapt the Empathy Fatigue Scale for Health Professionals (EFS-HP) into Chinese and evaluate its psychometric properties among ICU nurses. The EFS-HP was translated and adapted following Sousa's seven-step framework and Brislin's translation model. A convenience sample of 300 ICU nurses from a tertiary grade-A hospital in the Inner Mongolia Autonomous Region completed the Chinese EFS-HP and the Compassion Fatigue Scale for Medical Staff (CFS-MS). Item analysis, reliability testing (internal consistency, split-half, test-retest), and validity testing (content validity, exploratory and confirmatory factor analyses, convergent validity) were performed using SPSS 27.0 and AMOS 31.0. The Chinese EFS-HP retained all 21 items but yielded a two-factor structure-Emotional Load and Exhaustion State-accounting for 78.165% of the total variance. The scale demonstrated excellent internal consistency (Cronbach's α = 0.981), split-half reliability (Spearman-Brown = 0.938), and test-retest reliability (r = 0.958). Confirmatory factor analysis supported the two-factor model over the original single-factor model. The total score showed a moderate and statistically significant positive correlation with the CFS-MS (r = 0.587, P < 0.001), supporting convergent validity. The Chinese EFS-HP is a reliable and valid instrument for assessing empathy fatigue among ICU nurses and may serve as a practical screening tool to inform targeted mental health interventions.
To determine the prevalence and microbiological profile of ventilator-associated pneumonia (VAP) in mechanically ventilated patients and to assess clinical and laboratory parameters associated with its development, with emphasis on C-reactive protein (CRP) levels and duration of mechanical ventilation. This single-centre prospective observational cohort study included 118 adult patients who required invasive mechanical ventilation for more than 48 hours in the intensive care unit of the University Clinical Centre Tuzla. Patients were classified into VAP and non-VAP groups. Demographic, clinical, laboratory, and microbiological data were collected, and in-hospital outcomes were recorded. Statistical analysis included between-group comparisons, univariate logistic regression, and receiver operating characteristic (ROC) curve analysis. VAP was diagnosed in 41 patients (34.7%). Gram-negative pathogens predominated (≈ 85%), with Acinetobacter baumannii identified most frequently (43.9%), followed by Pseudomonas aeruginosa and Klebsiella pneumoniae. Patients with VAP had significantly longer durations of mechanical ventilation (12.5 vs. 7.3 days, p < 0.001) and hospitalisation (19.6 vs. 12.2 days, p < 0.001), as well as higher CRP levels (178.2 vs. 126.4 mg/L, p < 0.001). Reintubation, elevated CRP, leukocytosis, hypercapnia, and prolonged mechanical ventilation were associated with VAP. CRP demonstrated good-to-moderate discriminative ability for VAP (AUC = 0.83). VAP remains a common and clinically significant complication in mechanically ventilated patients. Elevated CRP levels and prolonged mechanical ventilation may support early clinical suspicion using routinely available parameters.
Background/Objectives: Achieving guideline-recommended low-density lipoprotein cholesterol (LDL-C) targets in patients with chronic coronary syndrome (CCS) remains challenging despite intensive lipid-lowering therapy. Bempedoic acid (BA) offers an oral therapeutic option, although data on its clinical performance and patient-level determinants of response in real-world Spanish settings are limited. Methods: We conducted a prospective multicentre study across the four healthcare areas of Cáceres province, Spain, including consecutive CCS patients with LDL-C ≥ 55 mg/dL despite stable intensive lipid-lowering therapy. BA 180 mg/day was added to background treatment. Lipid parameters, metabolic profile, and safety outcomes were assessed after a median follow-up of 28 weeks (IQR 23-47). Multivariable analyses were performed to identify factors associated with of LDL-C reduction and target attainment. A total of 118 patients were analyzed for outcomes. Results: A total of 118 patients (mean age 62.4 ± 10.0 years; 79.2% male) were included. BA reduced LDL-C by 22.8% (-16.36 mg/dL; p < 0.001), enabling 48.3% of patients to achieve LDL-C < 55 mg/dL. Higher baseline LDL-C (β = -0.515; p = 0.001) and the presence of diabetes mellitus (B = 13.8 mg/dL; p = 0.024) were independently associated with greater LDL-C reduction. Notably, 56.3% of patients presented with elevated baseline lipoprotein(a) levels (>50 mg/dL), describing a high underlying burden of residual risk. BA was well tolerated, with a modest increase in uric acid levels but no gout events and a high treatment persistence rate (94.4%). Conclusions: In a real-world CCS population receiving intensive lipid-lowering therapy, BA provides clinically meaningful LDL-C reduction with a favorable safety profile in this multicentre cohort from Cáceres province. Patients with higher baseline LDL-C and diabetes derive greater benefit, supporting a more personalized approach to therapy. These findings reinforce the role of BA in Spanish patients as an intermediate step in lipid-lowering strategies before escalation to more costly therapies, addressing the scarcity of local real-world data.
In an increasingly complex healthcare system, the use of nursing diagnosis is considered a gold standard of care and has become more integrated into clinical practice. Many countries have introduced policies to support the use of nursing diagnosis and align them with international nursing standards. In Romania, accreditation requirements have recently incorporated nursing diagnosis into clinical practice. However, although a legal framework exists, it remains unclear whether individual and organizational factors promote their use in daily practice. This study aims to examine the associations between individual factors (nurses' education, attitudes, and self-directed learning) and organizational factors (department size and type) and the use of nursing diagnosis in clinical practice, while accounting for theoretically relevant confounders. A cross-sectional survey was conducted among clinical and managerial nurses in Romanian hospitals. A total of 691 nurses participated, and the final sample included 589 participants. Data were collected using a multistage sampling strategy and analyzed using multilevel regression modeling. Multilevel regression analysis showed that positive attitudes and formal education were significantly associated with nursing diagnosis use, while lack of formal education or reliance on self-training was associated with lower use. Greater time dedicated to self-directed learning was associated with increased use. Older age, male gender, and larger department size were negatively associated with nursing diagnosis use, while use was lower in emergency and intensive care units compared to medical departments. Both individual and organizational factors are associated with the use of nursing diagnosis. Education, self-directed learning, and positive attitudes support their use, while department characteristics, older age, and male gender are associated with lower use. Targeted training and the promotion of self-directed learning may enhance the use in clinical practice. Nurse leaders should promote nursing diagnosis-focused education and continuing professional development tailored to nurses' prior training, support opportunities for self-directed learning, and implement structural measures in larger departments and adapted protocols in high-acuity settings where lower use was observed.
Post-endoscopic variceal ligation ulcer bleeding (PEBU) is a rare but life-threatening complication in cirrhosis, often refractory to standard therapy. While transjugular intrahepatic portosystemic shunt (TIPS) is effective, its complexity and risk of hepatic encephalopathy limit its use. Self-expandable metal stent (SEMS) offers a minimally invasive alternative, but comparative data are limited. This study evaluated SEMS versus TIPS in refractory PEBU. In this retrospective cohort study, 30 cirrhotic patients with refractory PEBU at a tertiary Indian center were treated with either SEMS (n=15) or TIPS (n=15). The primary endpoint was hemostasis within 72 hours without rebleeding within 5 days. Secondary outcomes included 12-week rebleeding, mortality, complications, and quality of life (Patient-Reported Outcomes Measurement Information System [PROMIS]-10). Baseline characteristics were comparable. Immediate hemostasis was achieved in 100% (SEMS) and 93.3% (TIPS) (p=0.31). Rebleeding rates were similar (13.3%). SEMS showed lower mortality (6.7% vs. 20%) and less hepatic encephalopathy (20% vs. 46.7%). SEMS showed superior PROMIS-10 scores (13.93±4.33 vs.10.07±4.57, p<0.001) and shorter intensive care unit stay (2 vs. 5 days, p=0.002). Stent migration occurred in 20%. SEMS provides outcomes comparable to TIPS with fewer complications and easier applicability, supporting its use in resource-limited settings.
Background Cardiorenal syndrome type 1 (CRS-1), manifesting as acute kidney injury (AKI) during episodes of acute decompensated heart failure (ADHF), constitutes a clinically significant complication with independent adverse effects on both short- and long-term patient outcomes. Delineating the clinical, echocardiographic, and biochemical factors predisposing to this complication is foundational to risk-guided cardiorenal management. Prospective regional data from the Indian subcontinent addressing this clinical question remain insufficient. Materials and methods A prospective observational investigation enrolled 100 sequential adults who met the 2021 European Society of Cardiology (ESC) criteria for ADHF and were admitted to the Intensive Cardiac Care Unit and Medical ICU at Maharishi Markandeshwar University of Medical Sciences and Research (MMIMSR), Ambala, Haryana, India. AKI was ascertained using the Kidney Disease: Improving Global Outcomes (KDIGO) 2012 serum creatinine thresholds after exclusion of competing aetiologies. Comorbid diagnoses, echocardiographic indices (Left Ventricular Ejection Fraction (LVEF), phenotypic classification), and admission biochemistry including serum sodium and N-terminal pro-B-type natriuretic peptide (NT-proBNP) were prospectively documented. Associations between different variables and AKI were evaluated using Chi-square analysis, independent-samples t-test or Mann-Whitney U test, unadjusted odds ratios (OR) with 95% confidence intervals, and ROC curve analysis. A two-tailed p-value below 0.05 denoted statistical significance. Results Half the enrolled cohort (50%) fulfilled criteria for AKI. The Heart Failure with Preserved Ejection Fraction (HFrEF) phenotype (LVEF ≤40%) was present in 80.0% of AKI patients relative to 68.0% of AKI-free patients (OR 1.88; 95% CI 0.73-4.82; χ² = 1.87; p = 0.171). Among comorbid conditions, only diabetes mellitus attained statistical significance (OR 4.37; 95% CI 1.89-10.08; χ² = 11.95; p < 0.001). Biochemically, AKI patients exhibited substantially higher median NT-proBNP (16,832.5 vs 6,599.5 pg/mL; p < 0.001), and lower serum sodium (135.96 ± 4.38 vs 137.98 ± 4.03 mEq/L; p = 0.018). NT-proBNP yielded the greatest discriminatory capacity (AUC 0.74; 95% CI 0.64-0.83), ahead of serum sodium (area under the curve (AUC) 0.64) and LVEF (AUC 0.60). Conclusion AKI is encountered in half of patients hospitalised with ADHF at a North Indian tertiary centre. Diabetes mellitus represents the predominant metabolic risk determinant, while admission NT-proBNP furnishes the strongest single-biomarker discriminatory signal. These routinely obtainable parameters constitute a clinically actionable framework for cardiorenal risk stratification at hospital admission.
Intravenous phentolamine mesylate and furosemide are widely administered via infusion pumps to treat severe pediatric critical illnesses. Their off-label concurrent use lacks reliable physicochemical compatibility and stability data, bringing potential medication safety risks. This study aimed to evaluate the 8-hour compatibility and stability of the two drugs mixed in syringes under simulated clinical in vitro conditions. Two clinically relevant concentration gradients were set for testing: phentolamine mesylate at 0.1 and 0.5 mg·mL⁻1, and furosemide at 0.5 and 1.0 mg·mL⁻1. Drug admixtures were prepared by dilute mixing using either 0.9% sodium chloride injection (0.9% NS) or 5% glucose injection (5% GS). All solutions were stored at room temperature (25 ± 1 °C) under natural light and sampled at 0, 2, 4, 6 and 8 h. Physicochemical indicators including appearance, pH value, insoluble particles and relative drug content were determined to assess mixture stability. Throughout the 8-hour observation period, all mixed solutions remained clear and colorless without precipitation, turbidity, or discoloration. The pH values remained stable with a fluctuation range within ±0.4 units. The number of insoluble particles complied with the standards specified in the 2020 edition of the Chinese Pharmacopoeia. Moreover, the relative percentage content of both phentolamine mesylate and furosemide remained above 95% at all time points. Under in vitro conditions at room temperature (25 ± 1 °C) with natural light exposure, admixtures of phentolamine mesylate (0.1 or 0.5 mg·mL⁻1) and furosemide injection (0.5 or 1.0 mg·mL⁻1) prepared via dilute mixing in either 0.9% NS or 5% GS remained physicochemically stable for up to 8 h. The findings are only valid for the specific experimental parameters in this work and cannot be generalized to routine off-label combined administration in pediatric critical care.
Artificial intelligence (AI) has driven major disruption across multiple domains of clinical medicine and patient care and is fundamentally redrawing the landscape of modern medicine. In this context, cytopathology stands at a critical crossroads, where traditional microscopic evaluation meets the frontier of computational medicine. Conventionally, a successful cytopathology workflow entails intensive manual effort performed under the close supervision of an expert cytopathologist and an experienced, highly competent team of cytotechnologists. With the advancements in medical science driven by the demand for precision and personalized medicine, workload of the cytopathology laboratory is ever increasing by many folds, while there is an alarming decreasing trend in the availability of skilled human resource. A new era of diagnostic precision is emerging, as machine learning and deep learning algorithms take center stage in the laboratory. These systems tend to streamline the workflow by reviewing high-volume slide sets, prioritizing high-risk cases, and offering prognostic insights. These processes are highly dependent on meticulous digitization of cytology smears using whole slide imaging pathology scanners, which in turn enables telecytology, large-scale data sharing, and the development of robust training datasets, all of which accelerate AI innovation. This review provides an overview of the technical processes and applications of AI-based cytopathology algorithms across different organ systems, workflow transformation (from preanalytical to quality control, telecytopathology, and integration with molecular diagnostics), and the various challenges and limitations in their adoption in the routine diagnostic workflow for patient care.
Venous congestion is an important pathophysiological mechanism impacting organ function in critically ill patients. However, congestion physiology is complex, can affect multiple organ systems, and is subject to change rapidly over time. Contemporary multimodal assessment integrates both traditional approaches and emerging technologies to refine our understanding and improve clinical evaluation of this dynamic process. In this review, we explore how combining various ultrasound assessments can enhance the evaluation of congestion in critically ill patients. Topics include diastolic function evaluation with echocardiography, the Venous Excess Ultrasound (VExUS) assessment, and lung ultrasound.
Intensive Care Unit-Acquired Weakness (ICU-AW) is a secondary neuromuscular disorder diagnosed during a critical illness and related to ICU stay and intensive treatments, once other possible etiologies have been excluded. Micronutrients are essential components of human nutrition that are needed in small amounts to maintain pivotal organ functions, but their role in critical care nutrition and in prevention and treatment of ICU-AW is unclear. This narrative review aimed to provide a synthesis of the current evidence on the potential role of micronutrients in ICU-AW, with a glance at what is known in medical settings outside the ICU. Available evidence is fragmented, showing controversial results. Studies on vitamin K1 and vitamin D suggest potential benefits on handgrip strength, skeletal muscle mass and mobility, while Coenzyme Q10 may have a role in improving skeletal muscle composition. Moreover, zinc homeostasis may influence muscle degradation, whereas copper levels may represent a risk factor. Evidence on iron and carnitine showed uncertain results. Conversely, more robust evidence on muscle weakness is available for medical settings outside the ICU. Larger observational studies and RCTs are needed to further evaluate the possible efficacy of micronutrient supplementation in the critical care setting.
Severe hypocalcemia affects 25-50% of patients with secondary hyperparathyroidism (sHPT) after total parathyroidectomy. It results from acute postoperative hypoparathyroidism and rapid skeletal mineral uptake. Severe hypocalcaemia leads to significant morbidity, prolonged hospital stays, and increased healthcare costs. Few risk assessment prediction tools exist; they lack external validation and exhibit methodological shortcomings. To enable evidence-based risk stratification and personalised perioperative management, we developed and internally validated a nomogram for predicting severe post-parathyroidectomy hypocalcaemia (SPPH) in patients with sHPT who underwent total parathyroidectomy with autotransplantation. This retrospective cohort study included 227 patients from two tertiary care institutions with sHPT who underwent total parathyroidectomy with autotransplantation between 2019 and 2024. All subjects had sHPT [parathyroid hormone (PTH) >3× upper limit of normal] in the context of stage 4-5 chronic kidney disease (CKD) or dialysis dependent. Patients with autonomous parathyroid function (calcium-independent PTH elevation) were excluded. Intensive calcium supplementation protocols were administered to all patients. SPPH was defined by: (I) serum calcium <1.9 mmol/L; (II) intravenous calcium requirement beyond postoperative day 3; (III) symptomatic hypocalcemia (tetany, seizures, arrhythmias, or laryngospasm) requiring intravenous calcium and/or urgent cardiac monitoring; or (IV) hospitalization ≥7 days primarily for calcium management. We employed the least absolute shrinkage and selection operator (LASSO) regression for variable selection, followed by multivariable logistic regression. Internal validation utilized 200 bootstrap resamples to derive the optimism-corrected performance estimates. The incidence of SPPH was 49.8% (113/227). Among 157 patients with complete predictor data, LASSO identified four optimal predictors: [adjusted odds ratio (OR) 0.87 per year, 95% confidence interval (CI): 0.76-0.99], preoperative phosphate at one month (adjusted OR 1.29 per mmol/L, 95% CI: 0.96-1.71), preoperative alkaline phosphatase (ALP) at one month (adjusted OR 4.11 per 100 U/L, 95% CI: 1.89-8.92), and preoperative PTH at three months (adjusted OR 0.87 per 10 pmol/L, 95% CI: 0.68-1.13). The model demonstrated good discrimination with an apparent c-statistic of 0.751 (optimism-corrected 0.739), good calibration (Hosmer-Lemeshow P=0.657), and positive net benefit across clinically relevant threshold probabilities of 0.1-0.8. Risk stratification yielded three clinically meaningful groups: low-risk (<30% predicted probability, n=25, 8.0% observed SPPH rate), intermediate-risk (30-70%, n=92, 58.7% rate), and high-risk (>70%, n=40, 72.5% rate). We developed and internally validated a nomogram for preoperative risk stratification of SPPH in patients receiving intensive calcium supplementation protocols using readily available preoperative variables, identifying ALP as the predominant risk factor. The prognostic significance of ALP offers a new perspective beyond the conventional emphasis on PTH levels and insight into the underlying mechanisms of post-operative hypocalcemia. The substantial gradient across risk groups (8.0-72.5%) supports personalized perioperative management. However, multicenter external validation is essential before clinical implementation. Once validated, this tool could enhance patient outcomes and streamline healthcare resources for thousands of patients undergoing parathyroidectomy annually.
In intensive care units (ICUs), patients are often unable to make medical decisions, requiring relatives to act as surrogate decision-makers, particularly for invasive procedures. However, there is no validated Turkish instrument to assess these needs. This study aimed to evaluate the validity and reliability of the Turkish version of the Surrogate Decision Needs Scale (SDNS). This methodological study was conducted in the intensive care unit of a state hospital in Türkiye between January and March 2026 and included 200 relatives of ICU patients. Content validity, construct validity and reliability were assessed using standard methods. Findings demonstrated high validity and reliability, with strong content validity (S-CVI = 0.98), good model fit indices (CFI = 0.97, RMSEA = 0.057, TLI = 0.97) and strong internal consistency (Cronbach's alpha = 0.817). Test-retest reliability was also excellent (ICC = 0.931-0.965). The Turkish SDNS is a valid and reliable tool for assessing surrogate decision-making needs in ICU settings.
Coronary artery bypass grafting (CABG) improves prognosis in advanced coronary artery disease but does not halt native-vessel atherosclerosis or prevent graft failure. This review summarizes key advances in secondary prevention after CABG, emphasizing contemporary evidence, treatment shortcomings, and practical implications for long-term care. Intensive lipid lowering remains key, with high-intensity statins, ezetimibe, and PCSK9 inhibitors used sequentially to achieve very low LDL-C targets, while triglyceride-lowering therapy may benefit selected high-risk patients. Aspirin remains the cornerstone of antithrombotic therapy, whereas dual antiplatelet therapy should be patient-specific. Routine long-term beta-blocker or renin-angiotensin system inhibitor therapy should be guided by established indications rather than CABG alone, while calcium channel blockers may have a role after radial artery grafting. SGLT2 inhibitors, GLP-1 receptor agonists, cardiac rehabilitation, smoking cessation, obesity management, vaccination, and mental health and cognitive screening have broadened secondary prevention beyond traditional risk-factor control. Secondary prevention after CABG is a lifelong, multidisciplinary strategy aimed at preserving graft function, slowing disease progression, improving quality of life, and reducing recurrent cardiovascular events. Contemporary care should be individualized according to clinical phenotype, conduit strategy, comorbidity burden, thrombotic and bleeding risk, functional status, and treatment burden. Future studies should clarify persistent evidence gaps in antithrombotic therapy, cardiometabolic treatment, graft-specific outcomes, rehabilitation delivery, adherence, and patient-centered care.
Pediatric sepsis is a high-stakes, time-sensitive emergency, yet early recognition in the emergency department (ED) remains inconsistent because presenting features are heterogeneous, early signs are nonspecific, and implementation capacity varies across hospitals. At the same time, evidence for bundle-based care has expanded, but important clinical questions remain regarding which recognition approaches are most reliable in frontline ED settings, which bundle elements are best supported, and why pathway uptake remains uneven. This narrative review was undertaken to address these questions and to clarify current evidence gaps relevant to pediatric emergency practice. This structured narrative review searched PubMed on March 15, 2026 for studies published from January 1, 2010 through March 15, 2026 using terms related to pediatric sepsis, emergency care, screening, early recognition, sepsis bundles, biomarkers, quality improvement, and digital decision support. We focused on ED-relevant studies addressing recognition strategies, bundle implementation, nursing or workflow processes, and emerging technologies. Titles and abstracts were screened against predefined inclusion and exclusion criteria, and the final literature set was synthesized thematically into recognition, management, implementation, and future-direction domains. No language filter was planned at search design, but the review was limited to studies with accessible English full-text data for analysis. Current evidence supports a layered ED recognition model that combines clinical assessment with structured screening, targeted biomarkers, and workflow-integrated digital support rather than reliance on any single tool. Evidence is strongest for bundle pathways improving process outcomes such as time to antibiotics, pathway activation, and compliance with first-hour care targets. By contrast, evidence for direct mortality benefit, stand-alone biomarker superiority, and routine use of artificial intelligence (AI)-enabled systems remains promising but inconsistent because studies are heterogeneous in definitions, populations, and implementation context. The literature also shows that success in general ED practice depends heavily on pediatric readiness, nursing-led escalation, local workflow design, and multidisciplinary coordination. Pediatric sepsis care in the ED should be organized around rapid recognition plus measurable, context-adapted bundle delivery. The clearest evidence gaps involve external validation of recognition tools in general EDs, more explicit evaluation of individual bundle components, harmonized operational definitions and bundle metrics, and implementation studies that test how digital support and nursing workflows can improve frontline performance.
Intravascular large B-cell lymphoma (IVLBCL) is a rare and aggressive subtype of extranodal diffuse large B-cell lymphoma characterised by selective proliferation of neoplastic lymphocytes within the lumina of small blood vessels. The disease often presents with nonspecific constitutional symptoms and can involve multiple organ systems, making diagnosis challenging and frequently delayed. We report the case of a 71-year-old man who presented with recurrent chest infections, significant unintentional weight loss, and abnormal liver function tests. Initial imaging performed as part of a malignancy workup suggested acute calculous cholecystitis, leading to surgical admission. Subsequent magnetic resonance cholangiopancreatography (MRCP) demonstrated no imaging evidence supporting cholecystitis but revealed hepatosplenomegaly and periportal lymphadenopathy. Despite broad-spectrum antimicrobial therapy and extensive investigation for infectious, autoimmune, and metabolic liver disease, the patient's condition progressively deteriorated, with worsening cholestatic liver dysfunction, hypoxemic respiratory failure, acute kidney injury requiring continuous renal replacement therapy, and eventual multiorgan failure. Due to persistent diagnostic uncertainty and ongoing clinical decline, an image-guided liver biopsy was performed. Histopathological analysis demonstrated intrahepatic IVLBCL. Following multidisciplinary discussion, treatment with high-dose methylprednisolone was initiated with the intention of proceeding to rituximab-based chemotherapy. However, the patient's clinical condition continued to deteriorate rapidly, precluding definitive chemotherapy. Following discussions regarding goals of care, palliative management was pursued, and the patient subsequently died in intensive care. This case highlights the diagnostic challenges associated with IVLBCL and emphasises the importance of considering an early biopsy, as this rare entity may rapidly progress to multiorgan failure if diagnosis is delayed.