Journal of Clinical Medicine

Research

11 pages, 221 KB

Open AccessArticle

Balancing Chloride and Glucose in Critical Illness: A 10 Year Study on Diluent Strategies and ICU Outcomes

by Payam Rahimi, Furkan Tontu, Batoul Khoundabi, Sinan Aşar, Çağatay Nuhoğlu, Tuğba Yücel Yenice, Nuri Burkay Soylu, Emral Canan and Zafer Çukurova

J. Clin. Med. 2025, 14(23), 8573; https://doi.org/10.3390/jcm14238573 (registering DOI) - 3 Dec 2025

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Abstract

Background: High-chloride solutions such as 0.9% saline are widely used for medication dilution in intensive care units (ICUs) and are an underrecognized source of hyperchloremia and acid–base disturbances. Excess chloride reduces the strong ion difference (SID), contributing to hyperchloremic metabolic acidosis and [...] Read more.

Background: High-chloride solutions such as 0.9% saline are widely used for medication dilution in intensive care units (ICUs) and are an underrecognized source of hyperchloremia and acid–base disturbances. Excess chloride reduces the strong ion difference (SID), contributing to hyperchloremic metabolic acidosis and worse clinical outcomes. This study evaluated the impact of replacing isotonic saline with 5% dextrose as a diluent on ICU outcomes in mechanically ventilated patients. Methods: In this retrospective cohort study, 4347 adult ICU patients requiring ≥12 h of mechanical ventilation were analyzed across two periods with different diluent strategies (2015–2018: saline-based; 2019–2025: chloride-sparing, dextrose-based). Demographics, comorbidities, illness severity (APACHE II, SOFA), fluid exposure, SID, and laboratory values over the first 48 h were compared. Predictors of mortality were identified using multivariate logistic regression. Results: Mortality decreased from 44.6% to 39.2% after adoption of chloride-sparing diluents (absolute reduction 5.4%, p = 0.003), despite similar renal function across periods. The later cohort demonstrated significantly higher SID (median 39 vs. 38 mmol/L; p < 0.001), lower chloride levels, and more favorable acid–base profiles. In 2015–2018, chloride showed a strong association with mortality (~12–13% increased odds per mmol/L), while in 2019–2025 the association persisted but was attenuated (~2% per mmol/L). SID emerged as a significant marker of improved acid–base balance after the diluent transition. pH remained the most powerful predictor of mortality in both periods. Mean glucose levels increased by ~30–40 mg/dL after switching to dextrose diluents, although insulin requirements did not change. Conclusions: Transitioning from chloride-rich to chloride-sparing diluents was associated with reduced ICU mortality and improved acid–base balance, without changes in renal function. However, modestly increased glucose levels highlight the need for strict glycemic monitoring. These findings support chloride-sparing strategies with robust glycemic monitoring in critical care. Full article

(This article belongs to the Special Issue Clinical Advances in Critical Care Medicine)

20 pages, 1932 KB

Open AccessArticle

Predicting Blood Pressure and Blood Pressure Variability in Spontaneous Intracerebral Hemorrhage in the Emergency Department Using Machine Learning

by Emmeline Leggett, Abigail Kim, Shriya Jaddu, Priya Patel, Nahom Y. Seyoum, Manahel Zahid, Angie Chan, Hassan Syed, Milana Shapsay, David Dreizin, Joshua Olexa, Jennifer A. Walker, Stephanie Cardona and Quincy K. Tran

J. Clin. Med. 2025, 14(21), 7800; https://doi.org/10.3390/jcm14217800 - 3 Nov 2025

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Abstract

Introduction: Spontaneous intracerebral hemorrhage (sICH) is a devastating type of stroke. Blood pressure reduction is crucial in its management and is well mentioned in current guidelines; however, the role of blood pressure variability (BPV) in emergency departments (EDs) has not been well [...] Read more.

Introduction: Spontaneous intracerebral hemorrhage (sICH) is a devastating type of stroke. Blood pressure reduction is crucial in its management and is well mentioned in current guidelines; however, the role of blood pressure variability (BPV) in emergency departments (EDs) has not been well studied. This study aimed to identify predictors of lower systolic blood pressure (SBP) (≤160 mmHg) and BPV at ED discharge and course, respectively. Methods: This is a retrospective study of prospectively collected data at a quaternary care center of adult patients diagnosed and treated with sICH between 1 January 2017 and 31 December 2020. The primary outcome of interest was SBP at ED discharge; this was divided into two groups: a control group composed of patients discharged with an SBP ≤ 160 mmHg and a comparison group composed of patients discharged with an SBP > 160 mmHg. Secondary outcomes included measures of BPV, specifically successive variation (SBPSV), and standard deviation (SBPSD) during ED course. Machine learning algorithms were used to identify predictors of SBP at ED discharge: SBPSV and SBPSV. Results: This study evaluated 142 patients, of which 85 (60%) were discharged with SBP ≤ 160 mmHg. The mean SBP at ED discharge was 133 (±16.1) mmHg for the control group and 184 (±21.3) for the comparison group (difference −51; 95% CI −58 to −45; p < 0.001). The top five predictors for the primary outcome identified by machine learning included initial SBP at ED triage, serum sodium, clevidipine administration, serum glucose, and serum creatinine. Predictors for secondary outcome included mechanical ventilation, serum glucose, and initial SBP at ED triage. Conclusion: Initial SBP was the top predictor of achieving a goal SBP ≤160 mmHg at ED discharge in patients with sICH. Predictors of increased BPV included mechanical ventilation, elevated serum glucose, and high initial SBP in the ED. While further studies are necessary to confirm our observations, clinicians should consider these factors when they care for patients with sICH. Full article

(This article belongs to the Special Issue Clinical Advances in Critical Care Medicine)

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19 pages, 871 KB

Open AccessArticle

Extracorporeal Membrane Oxygenation for Severe Hypoxemia in Burn Patients: Analysis from Taiwan National Health Insurance Research Database

by Jiun-Yu Lin, Yi-Ting Tsai, Chih-Yuan Lin, Hung-Yen Ke, Yi-Chang Lin, Jia-Lin Chen, Hsiang-Yu Yang, Chien-Ting Liu, Wu-Chien Chien, Chien-Sung Tsai, Po-Shun Hsu and Shih-Ying Sung

J. Clin. Med. 2025, 14(18), 6623; https://doi.org/10.3390/jcm14186623 - 19 Sep 2025

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Abstract

Background: Burn patients with severe inhalation injury and refractory hypoxemia are at high risk for cardiorespiratory failure and mortality. Extracorporeal membrane oxygenation (ECMO) has emerged as a potential rescue therapy, but its survival benefits in this population remain uncertain. This study aimed [...] Read more.

Background: Burn patients with severe inhalation injury and refractory hypoxemia are at high risk for cardiorespiratory failure and mortality. Extracorporeal membrane oxygenation (ECMO) has emerged as a potential rescue therapy, but its survival benefits in this population remain uncertain. This study aimed to evaluate the impact of ECMO on mortality in burn patients with severe lung injury, to identify risk factors associated with death, and to analyze causes of rehospitalization among survivors. Methods: We conducted a population-based, retrospective cohort study using the Taiwan National Health Insurance Research Database (NHIRD). Burn patients with severe hypoxia requiring mechanical ventilation between 2000 and 2015 were identified. A 0.25-fold propensity score matching was applied based on age, gender, and burn severity. Mortality rates, survival risk factors, and rehospitalization causes were analyzed between ECMO and non-ECMO groups. Results: Among 6493 eligible patients, ECMO-treated patients had a hospital mortality rate of 47.09%, compared to 38.71% in the non-ECMO group. Early-phase mortality was higher among ECMO patients (adjusted 1-year mortality HR: 3.19), but survivors demonstrated stable long-term outcomes. Pulmonary complications, cardiac dysfunction, and sepsis were the leading causes of death. Kidney failure and infections were the most common reasons for rehospitalization among survivors. Conclusions: This research offers a comprehensive real-world analysis of the effectiveness of ECMO in burn patients. While ECMO does not eliminate early mortality risk, it may provide critical support during acute phase in carefully selected burn patients with severe hypoxemia. Multidisciplinary care and early rehabilitation planning are essential to improve long-term outcomes. Further research is needed to refine patient selection and optimize ECMO strategies in this high-risk population. Full article

(This article belongs to the Special Issue Clinical Advances in Critical Care Medicine)

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12 pages, 1271 KB

Open AccessArticle

Nonlinear Associations of Uric Acid and Mitochondrial DNA with Mortality in Critically Ill Patients

by Max Lenz, Robert Zilberszac, Christian Hengstenberg, Johann Wojta, Bernhard Richter, Gottfried Heinz, Konstantin A. Krychtiuk and Walter S. Speidl

J. Clin. Med. 2025, 14(13), 4455; https://doi.org/10.3390/jcm14134455 - 23 Jun 2025

Cited by 1 | Viewed by 785

Abstract

Background: Mitochondrial DNA (mtDNA) has strong pro-inflammatory potential and was found to be associated with mortality in critically ill patients. The purine bases from circulating cell-free DNA, including mtDNA, are catabolised into uric acid, contributing to elevated systemic levels. However, the prognostic [...] Read more.

Background: Mitochondrial DNA (mtDNA) has strong pro-inflammatory potential and was found to be associated with mortality in critically ill patients. The purine bases from circulating cell-free DNA, including mtDNA, are catabolised into uric acid, contributing to elevated systemic levels. However, the prognostic value of uric acid in unselected critically ill intensive care unit (ICU) patients remains unclear. We aimed to investigate the association between uric acid levels at admission and 30-day mortality, assess its correlation with mtDNA, and examine prognostic relevance based on the primary cause of admission. Methods: This prospective single-centre study included 226 patients admitted to a tertiary care ICU. Uric acid and mtDNA levels were assessed at admission. Survival analyses were performed in the overall cohort and in subgroups stratified by primary diagnosis. Results: Uric acid showed a U-shaped association with 30-day mortality, with both low and high levels linked to reduced survival. In multivariate analysis, the 4th quartile of uric acid remained associated with adverse outcomes, independent of sex, vasopressors, mechanical ventilation, and creatinine (HR 2.549, 95% CI: 1.310–4.958, p = 0.006). A modest correlation was observed between uric acid and mtDNA (r = 0.214, p = 0.020). However, prognostic relevance varied by diagnosis. While uric acid predicted mortality in patients following cardiac arrest (p = 0.017), mtDNA was found to bear prognostic value in cardiogenic shock and decompensated heart failure (p = 0.009). Conclusions: Uric acid was independently associated with mortality in critically ill patients, with both low and high levels carrying prognostic value. Its predictive capabilities differed from mtDNA but showed partial overlap. However, both markers exhibited varying prognostic performance depending on the primary cause of admission. Full article

(This article belongs to the Special Issue Clinical Advances in Critical Care Medicine)

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Graphical abstract

16 pages, 1540 KB

Open AccessArticle

Emergency Department Vital Sign Variability Is Associated with Hematoma Progression in Spontaneous Intracerebral Hemorrhage

by Priya Patel, Abigail Kim, Milana Shapsay, Shriya Jaddu, Nahom Y. Seyoum, Anastasia Ternovskaia, Manahel Zahid, Hassan Syed, David Dreizin, Joshua Olexa, Afrah Ali, Stephanie Cardona, Quincy K. Tran and Jennifer A. Walker

J. Clin. Med. 2025, 14(13), 4404; https://doi.org/10.3390/jcm14134404 - 20 Jun 2025

Viewed by 1081

Abstract

Background/Objectives: Spontaneous intraparenchymal hemorrhage (sIPH) accounts for a significant proportion of strokes and is associated with an estimated 30-day mortality between 35 and 52%. Subsequent hematoma progression (HP) occurs in up to 30% of patients and is associated with blood pressure variability, [...] Read more.

Background/Objectives: Spontaneous intraparenchymal hemorrhage (sIPH) accounts for a significant proportion of strokes and is associated with an estimated 30-day mortality between 35 and 52%. Subsequent hematoma progression (HP) occurs in up to 30% of patients and is associated with blood pressure variability, increasing poor outcomes. This study evaluates systolic blood pressure and heart rate variability in the emergency department (ED) and HP in the first 24 h of admission. Methods: This retrospective study analyzed patients with sIPH presenting to the ED and transferred to a resuscitation unit between 2017 and 2020. Outcomes included the occurrence of HP. Variables included blood pressure variability as measured by the standard deviation in systolic blood pressure (SBP-SD), successive variation of systolic blood pressure (SBP-SV), standard deviation of heart rate (HR-SD), and successive variation of heart rate (HR-SV). Bivariate analysis and machine learning algorithms were used to identify ED predictors for HP. Results: Of the 142 records analyzed, 41 (29%) patients experienced HP. The medians [interquartile (IQR)] for baseline characteristics were similar between groups. In the group with no HP (control), the median [IQR] for SBP-SD was 17.6 [11–26] compared with 20.5 [13.9–26.1, p = 0.25]. The median [IQR] for standard deviation in SBP-SV was 18 [11.4–25.4] for the control group and 19.8 [15.2–27.3, p = 0.19] for the HP group. While bivariate analysis did not show statistical difference for SBP-SD, SBP-SV, HR-SD, or HR-SV, machine learning algorithms identified SBP-SD, HR-SD, and HR-SV as clinically impactful on HP with good accuracy (92.59% and 79.31%). Conclusions: This study suggests that there are factors in hyperacute hemodynamic management in the ED associated with HP among patients with sIPH. Full article

(This article belongs to the Special Issue Clinical Advances in Critical Care Medicine)

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17 pages, 1410 KB

Open AccessArticle

Inflammatory Indices in Patients with Myocardial Infarction Complicated by Cardiogenic Shock, and Their Interconnections with SCAI Stages and Patients’ Survival: A Retrospective Study

by Irina Kologrivova, Maria Kercheva, Oleg Panteleev, Alexey Dmitriukov, Ivan Zenkov, Tatiana Suslova and Vyacheslav Ryabov

J. Clin. Med. 2025, 14(12), 4283; https://doi.org/10.3390/jcm14124283 - 16 Jun 2025

Cited by 2 | Viewed by 1203

Abstract

Background: Myocardial infarction complicated by cardiogenic shock (MI-CS) remains a critical condition with high mortality rates, despite advances in treatment. Systemic inflammation plays a significant role in MI-CS progression; however, its dynamics across different stages of the Society for Cardiovascular Angiography and Interventions [...] Read more.

Background: Myocardial infarction complicated by cardiogenic shock (MI-CS) remains a critical condition with high mortality rates, despite advances in treatment. Systemic inflammation plays a significant role in MI-CS progression; however, its dynamics across different stages of the Society for Cardiovascular Angiography and Interventions (SCAI) classification remain poorly understood. This study aimed to evaluate indices of systemic inflammation—neutrophil–lymphocyte ratio (NLR), platelet–lymphocyte ratio (PLR), systemic immune-inflammation index (SII), systemic inflammation response index (SIRI), and aggregate index of systemic inflammation (AISI)—in MI-CS patients, correlating them with SCAI stages and survival outcomes. Methods: A single-center retrospective study included 132 patients with MI-CS, categorized into SCAI stages A–E. All patients were assessed for demographic, clinical, and laboratory data, procedural and treatment characteristics, MI timing, and outcomes. Complete blood count test data were used to calculate inflammatory indices and evaluate types of immune reactions. Results: PLR, SII, and AISI peaked at SCAI stage C and declined significantly at stage E, suggesting suppressed inflammation in advanced shock. SIRI emerged as a key prognostic marker for stage C patients, with elevated levels associated with larger infarct size, higher heart rate, and predominant innate immune activation. Patients with SIRI ≥ 3.34 had significantly lower two-year survival (log-rank test, p = 0.006). Conclusions: Inflammation indices, particularly SIRI, provide valuable prognostic insights in MI-CS, reflecting disease severity and heterogeneity of immune response. The decline in inflammatory indices at SCAI stage E may indicate immune suppression in extreme MI-CS, underscoring the need for personalized therapeutic strategies. Full article

(This article belongs to the Special Issue Clinical Advances in Critical Care Medicine)

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12 pages, 247 KB

Open AccessArticle

High-Flow Nasal Cannula Application After Extubation in Acute Respiratory Failure Patients

by Wen-Chi Chao, Shen-Yung Wang, Chang-Yi Lin, Hou-Tai Chang, Wen-Lin Su, Chien-Hua Tseng, Kuang-Yao Yang, Shih-Chi Ku, Kuo-Chin Kao and Chieh-Jen Wang

J. Clin. Med. 2025, 14(9), 3087; https://doi.org/10.3390/jcm14093087 - 29 Apr 2025

Viewed by 2439

Abstract

Background: The optimal timing of high-flow nasal cannula (HFNC) application in acute respiratory failure patients remains uncertain. This study aimed to investigate the impact of HFNC on the outcomes of patients with acute respiratory failure, focusing on its use after extubation. Methods: This [...] Read more.

Background: The optimal timing of high-flow nasal cannula (HFNC) application in acute respiratory failure patients remains uncertain. This study aimed to investigate the impact of HFNC on the outcomes of patients with acute respiratory failure, focusing on its use after extubation. Methods: This multicenter retrospective study enrolled adult acute respiratory failure patients requiring invasive mechanical ventilation during the first major outbreak of the COVID-19 pandemic in Taiwan from April to July 2021. Endpoints included prognosis after extubation as 28-day post-extubation mortality. Results: Among the patients, 107 received HFNC before intubation and 461 received conventional oxygen therapy (COT). Pre-intubation HFNC failure did not significantly affect hospital mortality but was associated with prolonged durations of mechanical ventilation and intensive care unit stay. Among 375 patients who underwent planned extubation, 158 received post-extubation HFNC and 217 received COT. HFNC application after extubation was associated with significantly reduced post-extubation 28-day mortality compared with COT. Conclusions: HFNC application after extubation is associated with reduced post-extubation 28-day mortality risks in acute respiratory failure patients who received planned extubation. Full article

(This article belongs to the Special Issue Clinical Advances in Critical Care Medicine)

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11 pages, 912 KB

Open AccessArticle

Does the Intensity of Therapy Correspond to the Severity of Acute Respiratory Distress Syndrome (ARDS)?

by Domenico Nocera, Stefano Giovanazzi, Tommaso Pozzi, Valentina Ghidoni, Beatrice Donati, Giulia Catozzi, Rosanna D’Albo, Martina Caronna, Ilaria Grava, Gaetano Gazzè, Francesca Collino, Silvia Coppola, Simone Gattarello, Mattia Busana, Federica Romitti, Onnen Moerer, Michael Quintel, Luigi Camporota and Luciano Gattinoni

J. Clin. Med. 2024, 13(23), 7084; https://doi.org/10.3390/jcm13237084 - 23 Nov 2024

Cited by 1 | Viewed by 2059

Abstract

Objectives: The intensity of respiratory treatment in acute respiratory distress syndrome (ARDS) is traditionally adjusted based on oxygenation severity, as defined by the mild, moderate, and severe Berlin classifications. However, ventilator-induced lung injury (VILI) is primarily determined by ventilator settings, namely tidal volume, [...] Read more.

Objectives: The intensity of respiratory treatment in acute respiratory distress syndrome (ARDS) is traditionally adjusted based on oxygenation severity, as defined by the mild, moderate, and severe Berlin classifications. However, ventilator-induced lung injury (VILI) is primarily determined by ventilator settings, namely tidal volume, respiratory rate, and positive end-expiratory pressure (PEEP). All these variables, along with respiratory elastance, are included in the concept of mechanical power. The aim of this study is to investigate whether applied mechanical power is proportional to oxygenation severity. Methods: We analyzed 291 ARDS patients (71 mild, 155 moderate, and 65 severe). We defined low, middle, and high mechanical power by dividing the entire population into tertiles with a similar number of patients. In each oxygenation class, we measured computed tomography (CT) anatomy, gas exchange, respiratory mechanics, mechanical power, and mortality rate. Results: ARDS severity was proportional to lung anatomy impairment, as defined by quantitative CT scans (i.e., lung volume and well-aerated tissue decreased across the ARDS classes, while respiratory elastance increased, as did mortality). Mechanical power, however, was similarly distributed across the severity classes, as the decrease in tidal volume in severe ARDS was offset by an increase in respiratory rate. Within each ARDS class, mortality increased from low to high mechanical power (roughly 1% for each J/min increase). Conclusions: Both lung severity and mechanical power independently impact mortality rates. It is tempting to speculate that ARDS severity primarily reflects the natural course of the disease, while mechanical power primarily reflects the risk of VILI. Full article

(This article belongs to the Special Issue Clinical Advances in Critical Care Medicine)

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10 pages, 501 KB

Open AccessArticle

Enhancing ICU Outcomes Through Intelligent Monitoring Systems: A Comparative Study on Ventilator-Associated Events

by Jui-Fang Liu, Mei-Ying Kang, Hui-Ling Lin and Shih-Feng Liu

J. Clin. Med. 2024, 13(21), 6600; https://doi.org/10.3390/jcm13216600 - 3 Nov 2024

Cited by 3 | Viewed by 3278

Abstract

Background: Using intelligent monitoring systems can potentially improve the identification and management of ventilator-associated events (VAEs). This single-center retrospective observational study evaluated the impact of implementing intelligent monitoring systems on the clinical outcomes of patients with VAEs in an ICU setting. Method: An [...] Read more.

Background: Using intelligent monitoring systems can potentially improve the identification and management of ventilator-associated events (VAEs). This single-center retrospective observational study evaluated the impact of implementing intelligent monitoring systems on the clinical outcomes of patients with VAEs in an ICU setting. Method: An intelligent VAE monitoring system was integrated into electronic medical records to continuously collect patient data and alert attending physicians when a ventilated patient met the criteria for a ventilator-associated condition, which was defined as an increase of at least three cm H₂O in positive end expiratory pressure (PEEP), an increase of at least 0.20 in the fraction of inspired oxygen (FiO₂), or the FiO₂ being over baseline for at least two consecutive days. This study covered two phases, consisting of before using the intelligent monitoring system (2021–2022) and during its use (2023–2024). Results: The results showed that patients monitored with the intelligent system experienced earlier VAE detection (4.96 ± 1.86 vs. 7.77 ± 3.35 days, p < 0.001), fewer ventilator-associated condition (VAC) occurrences, and a shorter total duration of VACs. Additionally, the system significantly reduced ventilator days, antibiotic use, and 14-day mortality. Conclusions: Intelligent monitoring systems enhance VAE management, improve clinical outcomes, and provide valuable insights into the future of critical care medicine. Full article

(This article belongs to the Special Issue Clinical Advances in Critical Care Medicine)

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Review

Jump to: Research, Other

15 pages, 969 KB

Open AccessReview

Physiology and Molecular Mechanisms of the “Third Fluid Space”

by Randal O. Dull and Robert G. Hahn

J. Clin. Med. 2025, 14(23), 8491; https://doi.org/10.3390/jcm14238491 (registering DOI) - 30 Nov 2025

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Abstract

Basic physiology and molecular mechanisms accounting for the maldistribution of fluid that is characteristic of the “third fluid space” (V_t2) have been known for several decades but have been poorly integrated into the clinical literature. Today, the maldistribution can be [...] Read more.

Basic physiology and molecular mechanisms accounting for the maldistribution of fluid that is characteristic of the “third fluid space” (V_t2) have been known for several decades but have been poorly integrated into the clinical literature. Today, the maldistribution can be quantified and simulated in living humans by using volume kinetic mathematics, which introduces possibilities to validate interventions designed to mitigate the pathophysiology. Fluid accumulation in V_t2 occurs both in fluid overload and inflammation, and both are largely influenced by interstitial fluid pressure. This is normally slightly sub-atmospheric but increases during volume loading to eventually exceed the ambient air pressure, whereby the loss of vacuum allows pools of fluid to appear in the interstitial gel. Opening of V_t2 due to fluid overload can be delayed/minimized by lowering the infusion rate, hemorrhage, and the use of hyper-oncotic fluid. Accumulation of fluid in V_t2 during acute inflammation and tissue injury can be explained by disruption of the cell–matrix interactions that actively regulate the interstitial pressure. Inflammatory mediators, mostly tissue cytokines, cause release of tensile forces that disrupt integrin-dependent adhesion between interstitial fibroblasts and collagen fibers. This disruption causes the interstitial space to expand, which results in a deep negative (suction) pressure. These events can be modulated by α-trinositol and insulin. Full article

(This article belongs to the Special Issue Clinical Advances in Critical Care Medicine)

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16 pages, 550 KB

Open AccessReview

Crossing Age Boundaries: The Unifying Potential of Presepsin in Sepsis Diagnosis Across Diverse Age Groups

by Edmilson Leal Bastos de Moura and Rinaldo Wellerson Pereira

J. Clin. Med. 2024, 13(23), 7038; https://doi.org/10.3390/jcm13237038 - 21 Nov 2024

Cited by 4 | Viewed by 1965

Abstract

Sepsis is a pervasive condition that affects individuals of all ages, with significant social and economic consequences. The early diagnosis of sepsis is fundamental for establishing appropriate treatment and is based on warning scores and clinical characteristics, with positive microbiological cultures being the [...] Read more.

Sepsis is a pervasive condition that affects individuals of all ages, with significant social and economic consequences. The early diagnosis of sepsis is fundamental for establishing appropriate treatment and is based on warning scores and clinical characteristics, with positive microbiological cultures being the gold standard. Research has yet to identify a single biomarker to meet this diagnostic demand. Presepsin is a molecule that has the potential as a biomarker for diagnosing sepsis. In this paper, we present a narrative review of the diagnostic and prognostic performance of presepsin in different age groups. Given its particularities, it is identified that presepsin is a potential biomarker for sepsis at all stages of life. Full article

(This article belongs to the Special Issue Clinical Advances in Critical Care Medicine)

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17 pages, 2463 KB

Open AccessReview

Critical Care Ultrasound in Shock: A Comprehensive Review of Ultrasound Protocol for Hemodynamic Assessment in the Intensive Care Unit

by Camilo Pérez, Diana Diaz-Caicedo, David Fernando Almanza Hernández, Lorena Moreno-Araque, Andrés Felipe Yepes and Jorge Armando Carrizosa Gonzalez

J. Clin. Med. 2024, 13(18), 5344; https://doi.org/10.3390/jcm13185344 - 10 Sep 2024

Cited by 6 | Viewed by 23648

Abstract

Shock is a life-threatening condition that requires prompt recognition and treatment to prevent organ failure. In the intensive care unit, shock is a common presentation, and its management is challenging. Critical care ultrasound has emerged as a reliable and reproducible tool in diagnosing [...] Read more.

Shock is a life-threatening condition that requires prompt recognition and treatment to prevent organ failure. In the intensive care unit, shock is a common presentation, and its management is challenging. Critical care ultrasound has emerged as a reliable and reproducible tool in diagnosing and classifying shock. This comprehensive review proposes an ultrasound-based protocol for the hemodynamic assessment of shock to guide its management in the ICU. The protocol classifies shock as either low or high cardiac index and differentiates obstructive, hypovolemic, cardiogenic, and distributive etiologies. In distributive shock, the protocol proposes a hemodynamic-based approach that considers the presence of dynamic obstruction, fluid responsiveness, fluid tolerance, and ventriculo-arterial coupling. The protocol gives value to quantitative measures based on critical care ultrasound to guide hemodynamic management. Using critical care ultrasound for a comprehensive hemodynamic assessment can help clinicians diagnose the etiology of shock and define the appropriate treatment while monitoring the response. The protocol’s use in the ICU can facilitate prompt recognition, diagnosis, and management of shock, ultimately improving patient outcomes. Full article

(This article belongs to the Special Issue Clinical Advances in Critical Care Medicine)

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Other

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13 pages, 1896 KB

Open AccessSystematic Review

Pneumocystis jirovecii Pneumonia Diagnosis with Oropharyngeal Wash PCR in Immunocompromised Patients—A Systematic Review

by Vasco Salgado Costa, José Pedro Cidade, Inês Medeiros, Pedro Fidalgo, Hugo Moreira, Teresa Miranda and Pedro Póvoa

J. Clin. Med. 2025, 14(18), 6572; https://doi.org/10.3390/jcm14186572 - 18 Sep 2025

Viewed by 1492

Abstract

Background/Objectives: Pneumocystis jirovecii pneumonia (PJP) remains a major cause of morbidity and mortality in immunocompromised patients. Bronchoalveolar lavage (BAL) is the diagnostic gold standard but is invasive and often impractical in critically ill patients. Oropharyngeal wash (OW) polymerase chain reaction (PCR) offers [...] Read more.

Background/Objectives: Pneumocystis jirovecii pneumonia (PJP) remains a major cause of morbidity and mortality in immunocompromised patients. Bronchoalveolar lavage (BAL) is the diagnostic gold standard but is invasive and often impractical in critically ill patients. Oropharyngeal wash (OW) polymerase chain reaction (PCR) offers a rapid, non-invasive alternative. We performed a systematic review focusing on this respiratory sample’s diagnostic accuracy and clinical utility. Methods: We searched PubMed, Scopus, Web of Science, Cochrane Library, and clinical trial registries including ClinicalTrials.gov and MedRxiv for studies of PCR-based P. jirovecii detection in OW samples from immunocompromised adults, using BAL or induced sputum as reference standards. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology was followed. Quality was assessed with Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2), and pooled sensitivity/specificity were estimated using a bivariate random-effects model. Results: Twelve studies (n = 633; 346 confirmed PJP cases) met the inclusion criteria. Most cohorts were human immunodeficiency virus (HIV)-positive. Pooled sensitivity was 68.3% (95% CI: 59.2–75.9) and specificity 91.8% (95% CI: 85.9–95.3); the area under the summary receiver operating characteristic curve (AUC) was 0.887. Diagnostic yield improved with pre-sample cough induction, 60-s gargling, early sampling before extended therapy, and higher fungal loads. Risk of bias was low, and no significant publication bias was detected. Conclusions: OW-based PCR delivers high specificity and moderate sensitivity for PJP diagnosis, offering a safe, scalable, and patient-friendly alternative when invasive testing is unfeasible. Optimizing collection protocols and expanding evaluation to non-HIV immunosuppressed populations could enhance its role as an early screening tool, enabling faster treatment decisions and reducing unnecessary antimicrobial exposure. Full article

(This article belongs to the Special Issue Clinical Advances in Critical Care Medicine)

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13 pages, 503 KB

Open AccessSystematic Review

Consensus-Based Recommendations for Assessing Post-Intensive Care Syndrome: A Systematic Review

by Helmar Bornemann-Cimenti, Johanna Lang, Sascha Hammer, Kordula Lang-Illievich, Sebastian Labenbacher, Stefan Neuwersch-Sommeregger and Christoph Klivinyi

J. Clin. Med. 2025, 14(10), 3595; https://doi.org/10.3390/jcm14103595 - 21 May 2025

Cited by 3 | Viewed by 4284

Abstract

Background: Post-intensive care syndrome encompasses physical, cognitive, and psychological impairments that persist in patients after discharge from an intensive care unit. There is considerable variation in the tools used for assessment. This systematic review aimed to summarize the consensus-based recommendations for assessing post-intensive [...] Read more.

Background: Post-intensive care syndrome encompasses physical, cognitive, and psychological impairments that persist in patients after discharge from an intensive care unit. There is considerable variation in the tools used for assessment. This systematic review aimed to summarize the consensus-based recommendations for assessing post-intensive care syndrome. Methods: A comprehensive literature search identified four consensus-based guidelines. A quality assessment carried out using the Appraisal of Guidelines for Research and Evaluation II tool demonstrated high methodological standards across all the included papers. Results: The guidelines consistently emphasize assessing cognition, mental health, and physical function as the core domains. However, there are notable differences in the specific tools recommended. Major et al. focused on physical examinations, while Mikkelsen et al. proposed a fundamental package of five tools covering the key domains. Spies et al. aimed for a pragmatic set of freely available instruments administrable within 30 min. Nakanishi et al. provided a detailed ranking of instruments for each domain. The availability of validated translations varied considerably across languages. Some tools developed specifically for post-intensive care syndrome were not considered by any consensus conference. Conclusions: Further work is needed to establish a universally accepted standard for assessing post-intensive care syndrome that considers practical implementation across diverse settings and languages. Full article

(This article belongs to the Special Issue Clinical Advances in Critical Care Medicine)

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12 pages, 1874 KB

Open AccessSystematic Review

Mortality in Critically Ill Patients with Liberal Versus Restrictive Transfusion Thresholds: A Systematic Review and Meta-Analysis of Randomized Controlled Trials with Trial Sequential Analysis

by Daniel Arturo Jiménez Franco, Camilo Andrés Pérez Velásquez and David Rene Rodríguez Lima

J. Clin. Med. 2025, 14(6), 2049; https://doi.org/10.3390/jcm14062049 - 18 Mar 2025

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Abstract

Background/Objectives: Anemia is common in critically ill patients, yet red blood cell (RBC) transfusion without active bleeding does not consistently improve outcomes and carries risks such as pulmonary injury, fluid overload, and increased costs. Optimal transfusion thresholds remain debated, with some guidelines [...] Read more.

Background/Objectives: Anemia is common in critically ill patients, yet red blood cell (RBC) transfusion without active bleeding does not consistently improve outcomes and carries risks such as pulmonary injury, fluid overload, and increased costs. Optimal transfusion thresholds remain debated, with some guidelines recommending a restrictive target of 7 g/dL instead of a more liberal target of 9 g/dL. Methods: We conducted a systematic review and meta-analysis following PRISMA guidelines, searching PubMed, EMBASE, and LILACS from January 1995 to October 2024. Thirteen randomized controlled trials involving 13,705 critically ill adults were included, with 6855 assigned to liberal and 6850 to restrictive transfusion strategies. The risk of bias was assessed using the Cochrane Risk of Bias Tool 2, and the pooled effect sizes were estimated with a random-effects model. We registered the protocol in PROSPERO International Prospective Register of Systematic Reviews (CDR42024589225). Results: No statistically significant difference was observed in 30-day mortality between restrictive and liberal strategies (odds ratio [OR] 1.02; 95% confidence interval [CI], 0.83–1.25; I² = 49%). Similarly, no significant differences emerged for the 90-day or 180-day mortality, hospital or intensive care unit (ICU) length of stay, dialysis requirement, or incidence of acute respiratory distress syndrome (ARDS). However, patients in the restrictive group received significantly fewer RBC units. The trial sequential analysis (TSA) indicated that the evidence accrued was insufficient to definitively confirm or exclude an effect on the 30-day mortality, as the required sample size was not reached. Conclusions: In conclusion, while our meta-analysis found no statistically significant difference in the short-term mortality between restrictive and liberal transfusion strategies, larger trials are needed to fully determine whether any clinically meaningful difference exists in critically ill populations. Full article

(This article belongs to the Special Issue Clinical Advances in Critical Care Medicine)

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Open AccessCase Report

Bilateral Serratus Plane Block in a Critically Ill, Mechanically Ventilated Patient with Multiple Rib Fractures Due to Severe Thoracic Trauma: Case Report and Literature Review

by Francesco Baccoli, Beatrice Brunoni, Francesco Zadek, Alessandra Papoff, Lorenzo Paveri, Vito Torrano, Roberto Fumagalli and Thomas Langer

J. Clin. Med. 2025, 14(6), 1864; https://doi.org/10.3390/jcm14061864 - 10 Mar 2025

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Abstract

Background/Objectives: Effective pain management in polytrauma patients with rib fractures is essential, particularly in the critical care setting. While epidural analgesia is considered the gold standard, it is not always feasible, necessitating alternative locoregional approaches. We present the case of a polytrauma [...] Read more.

Background/Objectives: Effective pain management in polytrauma patients with rib fractures is essential, particularly in the critical care setting. While epidural analgesia is considered the gold standard, it is not always feasible, necessitating alternative locoregional approaches. We present the case of a polytrauma patient with multiple, bilateral rib fractures and severe chest pain that hindered weaning from mechanical ventilation. A bilateral Serratus Anterior Plane Block (SAPB) was performed, with catheters placed for continuous administration of local anesthetics. Pain relief was immediate, enabling a rapid weaning from mechanical ventilation, safe extubation, and subsequent discharge to rehabilitation. A review of the literature on this technique in critically ill patients with thoracic trauma and multiple rib fractures is also presented. Methods: We conducted a literature search up to November 2024, identifying studies evaluating the use of SAPB in critically ill patients with chest trauma and rib fractures. Results: Eight studies were identified, including a total of 197 cases, of which only 3 involved a bilateral SAPB. Studies and published case reports demonstrated significant variability in analgesic protocols and reported outcomes. Notably, only two papers addressed specifically its role in facilitating weaning from mechanical ventilation. Conclusions: Pain control is fundamental in managing severe chest trauma. This case and the reviewed literature suggest that the SAPB is a promising option when epidural analgesia is contraindicated or impractical. However, further studies are needed to define its place in clinical practice and optimize its use in critically ill patients. Full article

(This article belongs to the Special Issue Clinical Advances in Critical Care Medicine)

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