Search Results (212)

A 65-year-old man with type 2 diabetes presented with abdominal pain. Although he had no typical reflux symptoms such as heartburn or acid regurgitation, esophagogastroduodenoscopy (EGD) showed findings suggestive of reflux esophagitis, and proton pump inhibitor therapy was initiated. Two months later, he was admitted with intractable vomiting. EGD demonstrated diffuse circumferential mucosal injury without black discoloration, predominantly in the distal esophagus. These findings were interpreted as severe reflux esophagitis (Los Angeles grade D; RE-D). Symptoms improved with supportive care, glycemic control, and continued PPI therapy; follow-up EGD showed marked improvement. Six months later, he re-presented with identical symptoms and endoscopic findings. Laboratory testing confirmed diabetic ketoacidosis (DKA), with ketonuria, elevated total ketone bodies (2469 µmol/L), and high-anion gap metabolic acidosis (anion gap 17.2 mEq/L). The diagnosis was revised to DKA-associated acute esophageal mucosal lesion (AEML). He improved with fluid resuscitation and insulin therapy, and medication adherence was reinforced. Follow-up EGD showed complete healing without recurrence. AEML has been proposed as a spectrum that includes acute esophageal necrosis (AEN; “black esophagus”) and esophagitis without black-appearing mucosa. This case highlights a diagnostic pitfall in which DKA-associated AEML without black discoloration may be misattributed to severe reflux esophagitis. When the clinical presentation or endoscopic appearance is severe or atypical, clinicians should consider AEML and evaluate for underlying systemic precipitants. Full article

Background: Cardiac tamponade (CT) is a rare but life-threatening medical emergency caused by fluid accumulation in the pericardial sac, impairing cardiac filling and reducing output. More than 20% of CT cases are iatrogenic. CT is a recognized complication of central venous catheter (CVC) placement, with mortality rates in pediatric patients reported to reach 50%. Clinical presentation is often nonspecific, and echocardiography remains the diagnostic gold standard. Case report: We present two pediatric cases of CT due to late CVC migration, managed in the pediatric intensive care unit (PICU). The first case involved a 25-day-old neonate with short bowel syndrome who received prolonged parenteral nutrition via CVC. Four days after catheter insertion, the patient developed sudden cardiocirculatory collapse. The second case featured a 2-year-old child with Leigh syndrome who required mechanical ventilation and multimodal pharmacological therapy. Six days after CVC placement, the patient developed acute hemodynamic deterioration. In both cases, echocardiography confirmed CT, while chest radiography suggested intracardiac positioning of the catheter tip. Management and outcome: Emergency pericardiocentesis and advanced cardiopulmonary resuscitation were performed. Despite transient hemodynamic stabilization, both patients developed multiorgan failure with fatal outcomes. Conclusions: CT is a critical complication in pediatric patients with CVCs. Accurate verification of catheter tip position is essential, and intracardiac placement should be avoided. Any sudden clinical deterioration in a patient with a CVC should raise suspicion of late catheter migration and requires immediate life-saving intervention. Full article

Sepsis remains a leading cause of preventable morbidity and mortality worldwide, and adherence to the Centers for Medicare & Medicaid Services Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) remains modest and variable across institutions. Simultaneously, controversy persists regarding fixed-volume fluid resuscitation mandates, particularly given the increasing emphasis on individualized, physiology-guided management. Artificial intelligence (AI) has emerged as a potential strategy to address both operational and clinical gaps in sepsis care. This review examines the current state of SEP-1 implementation, key barriers to compliance, and ongoing debates surrounding early fluid administration. We then discuss contemporary evidence on AI-enabled tools designed to accelerate bundle processes and support personalized fluid management. Early warning systems, natural language processing-augmented models, and telemedicine-integrated platforms have demonstrated improvements in process measures such as time-to-antibiotics and bundle component completion when embedded within defined clinical workflows. Reinforcement learning, causal machine learning, and predictive models offer promise for individualized fluid strategies, although most data remain retrospective and hypothesis-generating. Successful integration will require prospective validation, clinician-in-the-loop oversight, governance frameworks, and continuous monitoring for safety, equity, and model drift. AI should augment—rather than replace—clinical judgment to improve reliability, timeliness, and personalization in sepsis management. Full article

Background: Pediatric septic shock remains a major cause of morbidity and mortality and requires timely recognition and management across multiple hospital settings. Although intensive care support is critical, outcomes are also influenced by earlier phases of care, including emergency department recognition, first-hour treatment, inpatient monitoring, and timely escalation to the pediatric intensive care unit (PICU). Objective: We aimed to review pediatric septic shock across the full hospital trajectory, from emergency department recognition to PICU management and outcomes, with emphasis on diagnostic challenges, early treatment, escalation of care, and prognostic assessment. Methods: This narrative review was based on a structured literature search of PubMed/MEDLINE, Scopus, and the Cochrane Library, with emphasis on international guidelines, consensus statements, systematic reviews, and clinically relevant pediatric studies addressing recognition, resuscitation, escalation, intensive care management, and outcomes in pediatric septic shock. Results: Pediatric septic shock is best approached as a dynamic continuum rather than a single event. Early recognition is complicated by age-dependent physiology, nonspecific presentation, and delayed hypotension. Timely antimicrobial therapy, individualized fluid resuscitation, early vasoactive support, and repeated reassessment during the first hours are central to management. Ward surveillance and prompt escalation to PICU are critical, as delayed recognition of deterioration may worsen organ dysfunction and resource use. In the PICU, phenotype-informed hemodynamic support, fluid stewardship, respiratory support, and organ support are essential. Outcomes should be evaluated beyond mortality to include organ dysfunction burden, duration of support, length of stay, and longer-term functional recovery. Conclusions: Pediatric septic shock outcomes are shaped by the entire hospital care pathway rather than PICU treatment alone. A trajectory-based, continuum-of-care approach may improve timely diagnosis, escalation, and short- and longer-term outcomes. Full article

Patients with preload-dependent conditions are at high risk of hemodynamic instability from both hypovolemia and hypervolemia. In hypovolemic states, the presence of third spacing may be misleading and obscure true intravascular volume status. Therefore, management of critically ill patients should be guided by a thorough understanding of physiology and pathophysiology to appropriately address hemodynamic derangements. Overreliance on rigid protocols and protocol-driven care without adequate clinical judgment may, in some cases, adversely affect patient outcomes. Herein, we present a case of hypovolemia-induced hypotension in the setting of third spacing and concentric left ventricular hypertrophy. Full article

Background: Evaporative water loss from burn wounds is a major but often neglected component of early fluid requirements. Despite its physiological importance, no dedicated review has quantified acute post-burn evaporative water loss (TEWL) and its interaction with modern resuscitation strategies in over 40 years. Recent mass-casualty burn events in specialized centers have re-emphasized the clinical importance of accurate early fluid balance, which is particularly challenging. Methods: A scoping review (PRISMA-ScR) of historical quantitative studies and 23 contemporary (2015–2025) adult major-burn resuscitation cohorts was conducted. Expected TEWL was derived from Lamke benchmarks; interstitial edema was estimated from the only available regression of simultaneous fluid input and 24 h weight change. A novel TEWL/edema ratio was tested against resuscitation volume (mL/kg/%TBSA) and the established input/output (I/O) ratio. Results: In the acute phase, the median TEWL normalized to total body surface area was 71 mL/m²/h [52–79 mL/m²/h], allowing for calculation of the TEWL/edema ratio. The TEWL/edema ratio was inversely correlated with the resuscitation fluid dose (R² = 0.811) and the I/O ratio as well (R² = 0.86), crossing unity at 2.85 mL/kg/%TBSA. A ratio > 1 signals high evaporative drive and/or possible under-resuscitation; a ratio < 1 alerts to fluid creep before significant weight gain. Conclusions: The TEWL/edema ratio is the first physiology-grounded, easily calculable resuscitation endpoint that complements urine output by providing insight into whether administered fluid is lost as obligatory evaporation or sequestered as edema. Routine estimation of expected TEWL and early monitoring of the TEWL/edema ratio may help guide goal-directed burn resuscitation, especially when early excision is delayed or impossible. Given the substantial inter-individual variability, the ratio derived from aggregate data should not be interpreted as a patient-specific predictor. Full article

Background/Objectives: Acute pancreatitis in pregnancy and the early postpartum period (APIP) is an uncommon but potentially life-threatening condition associated with significant maternal morbidity. Physiological adaptations of pregnancy, recent obstetric surgery, and overlapping postoperative symptoms frequently obscure early diagnosis and complicate perioperative and critical care management. This review provides a clinically oriented, anaesthesiology-focused overview of APIP, integrating current evidence with perioperative decision-making, pain management strategies, and intensive care considerations relevant to obstetric practice. Methods: A narrative, clinically structured review of the literature was performed focusing on epidemiology, aetiology, diagnosis, severity stratification, and management of APIP. Anaesthesiology- and ICU-specific aspects are synthesised into a pragmatic management framework. Results: Gallstone disease and hypertriglyceridaemia remain the predominant causes of APIP, with most cases occurring in the third trimester or early postpartum period. Diagnosis relies on pancreatic enzyme elevation and pregnancy-adapted imaging strategies. Early goal-directed fluid resuscitation, effective multimodal analgesia, and timely initiation of enteral nutrition are key determinants of outcome. Therapeutic ERCP and laparoscopic cholecystectomy can be safely performed during pregnancy when clinically indicated and may reduce recurrence in biliary pancreatitis. Neuraxial analgesia provides effective, opioid-sparing pain control and may improve respiratory mechanics and haemodynamic stability. Persistent organ failure remains the strongest predictor of adverse outcome and should prompt early intensive care admission. Conclusions: APIP requires early recognition and severity-adapted, multidisciplinary management. Anaesthesiology-led strategies play a central role in optimising analgesia, haemodynamic stability, and timely escalation of care. Framing APIP within a perioperative and critical care context may improve maternal outcomes in this vulnerable patient population. Full article

Hemorrhagic shock remains one of the leading causes of preventable death for both civilian and military trauma. Fluid resuscitation is the primary treatment but requires constant monitoring, particularly for volume non-responsive patients susceptible to fluid overload, pulmonary edema, and other life-threatening conditions. To overcome fluid non-responsiveness, vasoactive drugs or vasopressors can be necessary adjuvants to fluid therapy but require tedious titrations that can be difficult to manage during mass-casualty situations. This study developed and evaluated automated closed-loop vasopressor controllers for hemorrhage scenarios. Ten physiological closed-loop controller (PCLC) configurations with different underlying functionalities were tuned to be either more aggressive or conservative to reach the target mean arterial pressure. A hardware-in-loop test platform with fluid-pressure responsiveness, derived from animal data, tested each controller across three different starting pressure scenarios. The platform successfully differentiated controller designs based on performance metrics. While some configurations overshot the target and others could not reach the target pressure, strong-performing PCLCs consistently reached and maintained the target quickly. Three candidate PCLCs outperformed the rest and will be evaluated across wider scenarios to develop a robust controller design. This work accelerates PCLC-driven vasopressor administration development, providing a necessary fluid resuscitation adjuvant for precise hemodynamic management in hemorrhagic trauma. Full article

Background and Clinical Significant: Patent ductus arteriosus (PDA) is a common cardiovascular disorder in extremely low-birth-weight (ELBW) infants, for which surgical ligation is indicated when pharmacologic closure fails. Sudden increases in afterload combined with immature myocardial contractility can lead to post-ligation cardiac syndrome (PLCS), which usually occurs within hours after surgery. However, acute intraoperative hemodynamic collapse during PDA ligation has rarely been described. Case Presentation: A preterm infant born at 24 weeks and 3 days of gestation with a birth weight of 890 g underwent emergency PDA ligation for a hemodynamically significant PDA (hs-PDA) refractory to pharmacological treatment. Fifteen minutes after skin incision, the infant developed desaturation, bradycardia, and non-measurable noninvasive blood pressure, which required immediate hemodynamic resuscitation with manual ventilation, fluid administration, and dopamine and dobutamine infusions. Hemodynamics gradually recovered after completion of ductal ligation, whereas oxygen saturation did not fully recover. Postoperative chest radiography revealed a left-sided pneumothorax, and oxygen saturation stabilized after pleural air aspiration. The subsequent clinical course was uneventful, and typical PLCS did not develop. Conclusions: This case suggests that intraoperative hemodynamic collapse during PDA ligation may share pathophysiologic features with PLCS, and that concomitant pneumothorax can further aggravate hemodynamic instability by worsening hypoxemia and reducing venous return. Full article

This narrative review integrates landmark studies, recent publications, and major clinical guidelines to highlight the current state of the art concerning acute pancreatitis, a well-known yet still challenging condition. We will focus on recent practice transitions and future perspectives arising from advances in diagnostic imaging and interventional endoscopy. Pathogenesis and etiology: We carry out an overview of the fundamental mechanisms underlying acute pancreatitis, followed by an analysis of both common and uncommon causes, along with emerging evidence regarding idiopathic forms. Diagnosis and risk stratification: We pursue two objectives: on one hand, to emphasize the enduring importance of clinical assessment in the diagnosis of acute pancreatitis; on the other, to analyze the increasingly central role that imaging has acquired over recent decades. Identification of patients at higher risk for complications or an unfavorable prognosis is crucial. Several scoring systems have been proposed over the past decades, but with limited impact on daily clinical practice. Treatment: Therapeutic approaches have undergone significant revisions over time. Our objective is to provide an overview of the current standards together with best evidence-based medical approaches, targeted and interventional therapies, with focus on the endoscopic ones. Furthermore, we want to clarify the importance of nutrition and its proper management. Conclusions: Acute pancreatitis continues to stimulate discoveries and improvements in clinical management. We will place emphasis on unmet needs and emerging innovations that may importantly influence future practice also promoting evidenced-based standards of care. Full article

Background: Non-invasive intrauterine resuscitation measures, such as maternal repositioning and intravenous fluid therapy, are used in the presence of suspicious or pathological cardiotocographic (CTG) patterns during labor. However, evidence regarding their link with CTG abnormalities, amniotic fluid color, and immediate neonatal outcomes is limited. Objectives: To analyze the link between maternal repositioning and intravenous fluid therapy and the occurrence of suspicious or pathological intrapartum CTG patterns, as well as their relationship with amniotic fluid color and immediate neonatal effects. Methods: An analytical, observational, prospective study was conducted in women in labor with continuous monitoring. Changes in maternal position, administration of intravenous fluid therapy, CTG patterns, amniotic fluid color, and immediate neonatal outcomes were analyzed. Links were evaluated using appropriate statistical tests, considering maternal positions in isolation and in combination. Results: Maternal repositioning, both alone and in combination, was associated with the presence of suspicious or pathological CTG and with statistically significant differences in the 5 min Apgar score when analyzed as a continuous variable. No significant association was observed between intravenous fluid therapy and CTG patterns or neonatal outcomes. The presence of meconium-stained amniotic fluid was associated with a higher frequency of suspicious or pathological CTG. Conclusions: Maternal repositioning was most frequently applied as a clinical response to a suspicious CTG. Intravenous fluid therapy showed no link with CTG abnormalities or adverse neonatal outcomes. These findings reinforce the need to interpret intrapartum CTG in an integrated manner with the overall clinical context and support the use of maternal repositioning as a non-invasive measure in intrapartum management. Full article

There is a substantial correlation between cardiac dysfunction and elevated mortality in sepsis. Impaired myocardial perfusion, direct myocardial injury, and mitochondrial dysfunction are all part of the complex pathophysiology of sepsis-induced myocardial dysfunction. Recent evidence has shown the critical role mitochondrial dysfunction plays in the development of sepsis-induced myocardial dysfunction. In order to prevent and treat sepsis-induced myocardial dysfunction, a variety of drugs have been proposed. However, patient outcomes have not been appreciably enhanced by this therapy. This underscores the need for novel treatment approaches that target the specific pathways underlying cardiac dysfunction in sepsis. The prognosis is greatly impacted by sepsis-induced cardiac dysfunction, monitoring it is crucial. Clinicians employ a mix of clinical evaluations, hemodynamic monitoring, echocardiography, and bSICiomarkers to efficiently monitor this illness. The combined application of these techniques provides a comprehensive evaluation of cardiac function, thereby supporting timely optimization of treatment strategies. Treatments for septic shock and established sepsis will be beneficial for patients with this condition. However, there is little information and evidence about more targeted therapy, except than general management with vasopressors, inotropes, and fluid resuscitation. This study provides an outline of current knowledge on the pathophysiological mechanisms underlying sepsis-induced cardiac dysfunction, as well as the effects of monitoring and current treatments on sepsis-induced myocardial dysfunction. Full article

Background and Objectives: Severe burn injuries are still associated with high mortality. The length of intensive care stay is strongly influenced by the severity of organ failure, with multi-organ failure being the main cause of death in up to 40% of cases. Liver dysfunction is the second most common organ failure. Conventional diagnosis relies on static laboratory parameters that reflect damage already caused. Measuring the hepatic clearance of indocyanine green (LiMON^®) offers a dynamic, bedside method for detecting liver dysfunction early, enabling timely therapy adjustments. Materials and Methods: In this prospective single-centre observational study, all patients admitted to the Unfallkrankenhaus Berlin Burns Centre from October 2022 to September 2024 with ≥30% TBSA burns were included. Liver function was assessed via LiMON^® within 24 h post-injury and every 48 h until day 14 or ICU discharge. Static liver parameters were measured in parallel. Results: We included a total of 23 patients. An initial measurement was only successful in 18 cases. On admission, six patients (33%) had normal liver function with a plasma duration rate (PDR) > 18% (PDR 30.9 ± 7.3%), while 12 (67%) showed reduced clearance (PDR 14.5 ± 2.6%). In 75% of cases (n = 9), function recovered within 48 h. Based on PDR progression, four liver function patterns were defined: “stable”, “recovery”, “late insufficiency”, and “failure”; a fifth pattern included all patients who were deceased during this study (“death”). These groups differed in fluid therapy, plasma transfusion, and catecholamines administered. PDR correlated well with aminotransferase levels. Conclusions: Dynamic liver function monitoring enables earlier detection of impairment than static markers. Early identification of at-risk patients could guide fluid management and improve outcomes. LiMON^® is a valuable tool in burn care, though alternative methods may be needed in patients with severe systemic hypoperfusion. Full article

Background and Objectives: Traumatic hemorrhage is a leading cause of death. Our aim was to examine the effect of adenosine, lidocaine and magnesium (ALM) resuscitation therapy with and without fresh frozen plasma (FFP) or fresh whole blood (FWB) in a rat model of non-compressible hemorrhage. Materials and Methods: Anesthetized adult male Sprague-Dawley rats (439 ± 46 g) randomly assigned to (1) Shams (surgical trauma and liver isolation only without hemorrhage) (n = 34), (2) Saline controls (n = 34), or (3) ALM therapy (n = 34), underwent liver resection and uncontrolled bleeding. After 5 h 3% NaCl ± ALM bolus and 0.9% NaCl ± ALM drip fluid resuscitation, each group was randomized to receive no transfusion (NT) (n = 10 per treatment group), FFP (n = 12), or FWB (n = 12), and monitored for 72 h. Survival, hemodynamics, lactate, hematology, coagulation, platelet function, and lung histopathology were measured. Results: Sham, Saline and ALM NT survival were 50%, 0% and 100%. Sham survival increased to 75% with FFP, but not FWB (50%), and only marginally in the Saline group (8% and 17%, respectively). ALM protection was lost after 1–2 days with FFP and FWB (8% and 0% survival). Mortality was associated with acute lung injury, inflammation, activation of innate immunity, intrinsic hypocoagulopathy, and metabolic acidosis. Survival was associated with maintained platelet count and aggregation. Acute phase protein fibrinogen increased ~2.5 times in both survivors and non-survivors. Conclusions: ALM therapy without FFP or FWB transfusion significantly improved survival, reduced lung injury, preserved platelet function, and decreased immune and metabolic dysfunction. Blood products administered 5 h after injury did not significantly improve survival after non-compressible hemorrhage. Surgical trauma (laparotomy and liver isolation) also contributed to poor outcomes. The trauma and transfusion-related multi-system failure requires further investigation. Full article

Background: Fulminant type 1 diabetes (FT1D) is a rare but life-threatening subtype of type 1 diabetes. The concurrence of FT1D with myocarditis is uncommon and attracts further clinical attention. Case Presentation: A 33-year-old female was transferred by a local hospital to West China Hospital because of altered consciousness, abrupt onset of hyperglycemia with ketoacidosis, significantly increased cardiac biomarkers, and ST segment elevations. Her random blood glucose at the local hospital was 50.19 mmol/L. Insulin infusion and fluid resuscitation were started immediately before referral. On admission, her random blood glucose was 14.17 mmol/L. HbA1C and glycosylated albumin (GA) were 6.3% and 21.45%, respectively. Her fasting C-peptide level was 0.022 nmol/L. Anti-Glutamic Acid Decarboxylase (anti-GAD) antibody was 25.06 IU/mL. FT1D was diagnosed based on the 2012 New Diagnosis Criteria of FT1D. Electrocardiogram showed significant ST segment elevation in leads II, III, aVF, and V3-V6. Echocardiography revealed a mildly reduced left ventricular ejection fraction (LVEF) of 46%. Coronary angiography displayed no abnormality. Cardiac magnetic resonance imaging revealed areas of increased signal intensity in the interventricular septum, basal and mid inferolateral walls, and apical inferior wall and subepicardial late gadolinium enhancement (LGE), particularly in the lateral aspects of the left ventricle on T2-weighted imaging (T2WI). Acute myocarditis was diagnosed based on the European Society of Cardiology 2013 Task Force Criteria. She was treated with insulin, fluid resuscitation, and supportive care, leading to rapid recovery of ketoacidosis and cardiac function. At the four-month follow-up, she remained on insulin therapy with good glycemic control but persistent low C-peptide levels. Conclusion: This case report raises awareness about FT1D, determines the differential diagnosis of acute cardiac presentations in an FT1D patient, and highlights clinical reasoning so that clinicians can recognize and manage similar presentations on time. Full article