Search Results (60)

The introduction of respiratory multiplex PCR in the post-pandemic world has improved the detection of viral infections, whose clinical relevance is still being characterized. Patients with diabetes mellitus (DM) exhibit altered innate immune responses, yet the effect of concurrent viral infection on their inflammatory trajectory and clinical outcomes remains poorly characterized. This study examined whether diabetes is associated with a more pronounced inflammatory response, delayed resolution, and worse multi-organ outcomes during viral respiratory infections. A prospective, longitudinal cohort of 430 hospitalized adults (DM: n = 211; non-DM: n = 219) with PCR-confirmed viral respiratory infections was stratified into four groups by diabetes and co-infection status using a respiratory multiplex PCR panel. Serum IL-6, CRP, NLR, procalcitonin, and urea were measured at admission (Day 1) and at clinical stabilization (Day 6). All variables failed normality testing (Shapiro–Wilk p < 0.0001); non-parametric methods were applied. Receiver operating characteristic (ROC) analysis was used to identify candidate biomarker cutoffs for mortality prediction. SARS-CoV-2 was the predominant pathogen (29.1%). In an exploratory comparison limited by small subgroup sizes (n = 8 vs. n = 14), co-infected diabetic patients had higher baseline inflammatory markers than co-infected non-diabetic patients: median IL-6 32.87 vs. 6.20 pg/mL (Mann–Whitney p = 0.0006) and median CRP 103.83 vs. 23.03 mg/L (p = 0.0012). At the Day 6 checkpoint, co-infected diabetic survivors had higher IL-6 (12.01 vs. 6.13 pg/mL, p = 0.0183) and showed little within-group NLR change (Wilcoxon p = 0.2367); these Day 6 estimates are subject to survivor selection and should be interpreted accordingly. In-hospital mortality was 25.6% in diabetic vs. 3.7% in non-diabetic patients (p < 0.0001). Diabetic patients more frequently required orotracheal intubation (6.4% vs. 1.0%, p = 0.0207) and high-flow nasal oxygen (HFNO) support (7.9% vs. 1.8%, p = 0.0166). In an internal ROC analysis, baseline IL-6 showed the highest discriminatory performance for in-hospital mortality (AUC 0.812, 95% CI 0.772–0.848), with a candidate cutoff of > 55.78 pg/mL (sensitivity 71.0%, specificity 79.1%); IL-6 outperformed CRP (AUC 0.706, DeLong p = 0.0029) and NLR (AUC 0.656, DeLong p = 0.0001). As this cutoff was derived and evaluated in the same cohort, it is reported as exploratory and requires external validation. In this single-center cohort, diabetes was associated with a more pronounced baseline inflammatory profile, slower resolution of the neutrophil-to-lymphocyte ratio, and greater multi-organ involvement during viral respiratory infection, including in the small co-infected subgroup. In the full cohort, diabetes remained associated with higher mortality, IL-6, and CRP after adjustment for age, sex, and BMI; however, the small co-infected subgroups could not be adjusted, so those specific comparisons should be regarded as hypothesis-generating and need confirmation in larger, adequately powered multi-center cohorts. Full article

Background: Accurate endotracheal tube (ETT) insertion depth is critical in infants and young children, where tracheal malposition carries significant risk. Formula-based depth estimation is widely used at the bedside, but the performance of published formulas in children under two years of age admitted to a general PICU remains poorly characterized. Methods: A retrospective, single-center study was conducted at the PICU of King Saud Medical City, Riyadh. A total of 115 patients aged 1–24 months requiring orotracheal intubation were included. ETT depth was predicted using five established formulas: height-based [(H/10)+5], weight-based [W+6], ETT size-based [ETT×3], Lee weight-based [5.5+0.5W], and Lee height-based [3+0.1H]. Agreement between predicted and radiographically confirmed insertion depth was assessed using Lin’s concordance correlation coefficient (CCC), Bland–Altman analysis, and clinical classification of predictions. Results: None of the five formulas achieved acceptable concordance (CCC < 0.75 for all). The height-based formula performed best among published formulas, with negligible bias and the highest proportion of clinically acceptable predictions. Both Lee formulas showed near-universal systematic underestimation and are not suitable for this age group. Over half of all intubations resulted in non-ideal ETT position on the first post-intubation chest X-ray. Novel cohort-derived regression equations outperformed all published formulas, with the weight-based equation (Depth = 0.385 × Weight + 9.145) emerging as the strongest predictor of insertion depth. Conclusions: No published formula achieved reliable concordance with radiographic ETT depth in children aged 1–24 months. The cohort-derived weight-based formula represents a more accurate bedside tool for this population and warrants prospective external validation. Post-intubation radiographic verification remains essential. Full article

Background/Objectives: Hypoglossal nerve palsy is a rare but disabling complication of general anesthesia, typically associated with tracheal intubation and head and neck surgery. This study evaluated the incidence, clinical characteristics, and potential mechanisms of postoperative tongue deviation after breast reconstruction and other surgeries performed under general anesthesia with orotracheal intubation. Methods: We retrospectively reviewed 240,646 consecutive general anesthetic procedures with orotracheal intubation performed at two tertiary hospitals between September 2011 and October 2025. Eighteen patients who developed new-onset postoperative tongue deviation were identified, and demographic features, surgical department, breast reconstruction status, anesthetic details, patient positioning, laterality of deviation, symptom duration, and recovery outcomes were analyzed. Results: Postoperative tongue deviation was documented in 18 patients, corresponding to an overall incidence of approximately 0.01%, most frequently after breast reconstruction (7/18, 38.9%), followed by vascular (27.8%), head and neck tumor (16.7%), neurosurgical (11.1%), and hepatobiliary–pancreatic surgery (5.6%). All seven breast-reconstruction cases occurred at the breast-cancer center hospital, corresponding to 0.31% of 2256 breast reconstructions. The median age was 58.0 years; 66.7% patients were female. Most patients (77.8%) achieved complete recovery, whereas 16.7% had residual deviation. Conclusions: Postoperative hypoglossal nerve palsy with tongue deviation is an exceptionally rare event after general anesthesia. In our two-center cohort, it was observed most frequently among patients undergoing breast reconstruction at one participating center; this pattern is confounded by institution-specific anesthetic and positioning practices and should not be interpreted as evidence that the procedure itself carries inherent risk. The findings are hypothesis-generating and suggest that prolonged operating time, repeated intraoperative position changes, and specific head-fixation and tube-fixation practices warrant prospective investigation. Meticulous head–neck alignment, careful tube fixation, and a structured postoperative cranial-nerve check (tongue-protrusion and voice-quality assessment in the recovery room and on postoperative day 1) may aid the early detection of this complication. Full article

Background/Objectives: Pupillometry offers a non-invasive method for assessing nociceptive responses during anesthesia. This study aimed to evaluate the effects of intravenous lidocaine on pupillary reflex dilation (PDR) and the Pupillary Pain Index (PPI) during general anesthesia with orotracheal intubation. Methods: In this prospective, randomized, single-blind trial, 90 ASA I–II patients aged 18–65 years, scheduled for elective surgery under general anesthesia, were enrolled. Participants were randomized into three groups: control, study (lidocaine 1.5 mg/kg), and placebo. Standardized anesthesia induction was performed using propofol, fentanyl, and rocuronium. Pupil diameter was measured using the Algiscan pupillometer. PDR was assessed during intubation, while PPI was measured five minutes post-intubation through controlled electrical stimulation. Hemodynamic parameters and BIS values were recorded throughout. Eighty-six patients completed the study. No significant differences in demographics, anesthetic drug doses, or hemodynamic parameters were noted between groups. Results: PDR during intubation showed no significant difference between the control and study groups (median dilation: 0.34 mm vs. 0.33 mm; p = 0.76), but was significantly lower in the lidocaine group compared to placebo (median dilation: 0.33 mm vs. 0.50 mm; p = 0.02). PPI scores did not differ significantly between groups (p > 0.05). A positive correlation was observed between PDR and BIS values, indicating that lighter anesthesia depth increased PDR response. No such correlation was found with PPI. Conclusions: Intravenous lidocaine attenuates the pupillary response to nociceptive stimuli during orotracheal intubation but does not influence PPI scores. Pupillometry remains a valuable adjunct for intraoperative nociceptive monitoring. Full article

Patients with multiple traumas, particularly those with traumatic brain injury (TBI), are among the most challenging cases in intensive care medicine. Although early orotracheal intubation and invasive mechanical ventilation (IMV) are essential for airway protection and neurological treatment, they significantly increase the risk of lower respiratory tract infection (LRTI), including ventilator-associated pneumonia (VAP) and ventilator-associated tracheobronchitis (VAT). These complications are particularly prevalent among neurocritical patients due to the distinctive interaction between the brain, lungs and immune system. This narrative review examines the current evidence on the mechanisms underlying the brain–lung–immune axis; the diagnostic challenges in identifying respiratory infections in mechanically ventilated TBI patients; and optimal approaches to empirical or quasi-targeted antimicrobial therapy based on diagnostic algorithms and rapid molecular techniques. Severe TBI induces neurogenic inflammation, autonomic dysregulation, and immunosuppression, thereby increasing susceptibility to pulmonary infections. The ‘triple hit hypothesis’ best explains this cascade: sympathetic hyperactivity (first hit), iatrogenic ventilatory injury (second hit), and intestinal dysbiosis with systemic immune dysregulation (third hit). VAP diagnosis remains challenging due to the lack of universal criteria, the overlap with systemic inflammatory response syndrome, and the low specificity of radiological and clinical signs. VAT may represent an intermediate stage within a continuum of ventilator-associated infection. Recent evidence supports the selective use of nebulized antibiotics for VAT, advocating an individualized, locally adapted empirical approach to VAP treatment. Syndromic molecular panels can accelerate the identification of pathogens, enabling the earlier and more appropriate selection of antimicrobials and improving outcomes while preserving stewardship. Understanding the brain–lung–immune axis and improving diagnostic accuracy are essential to enhancing the treatment of respiratory infections in neurocritical care. Integrating clinical assessment, biomarkers and rapid microbiological testing enables timely, targeted therapy and reduces the misuse of antimicrobials. Full article

Objectives: To assess risk factors for post-extubation stridor in children and its impact on clinical outcomes. Methods: Prospective cohort study with children aged from 0 to 13 years who were intubated or underwent orotracheal intubation in the pediatric intensive care units (PICU) of two tertiary public hospitals. The outcome of interest was the occurrence of post-extubation stridor. The information collected included patient characteristics, comorbidities, history of airway manipulation, and factors related to orotracheal intubation. A logistic regression was used to identify potential risk factors for post-extubation stridor; data were analyzed until hospital discharge, death, or referral to another facility. Results: A total of 239 children were included, with a median age of 1.3 years and a duration of intubation of three days. Post-extubation stridor was observed in 57.3% of children. A multivariate analysis included prehospital or non-specialized hospital intubation, trauma or complications during intubation, and orotracheal intubation longer than seven days as risk factors for stridor. Children with stridor had a longer PICU length of stay, longer duration of invasive mechanical ventilation, and were often managed with non-invasive ventilation (p < 0.05). Most children with extubation failure (p = 0.001) and cardiorespiratory arrest (p = 0.03) presented with stridor. Conclusions: Risk factors for post-extubation stridor included intubation performed in prehospital or non-specialized hospitals, orotracheal intubation longer than seven days, and trauma or complications during intubation. Children with stridor had a worse prognosis, with longer stays in the PICU and on mechanical ventilation and higher rates of extubation failure. Full article

Introduction: Sepsis-induced cardiac dysfunction (SICD) is a reversible type of cardiac disorder, with variable reported incidence and uncertain prognostic implications that may occur in patients with sepsis. This study aimed to identify patients with SICD, characterise their clinical and paraclinical features, analyse the different patterns of cardiac dysfunction, and determine prognostic implications. Methods: Patients admitted to the intensive care unit (ICU) for sepsis or septic shock who underwent echocardiography on admission were identified retrospectively. Exclusion criteria included acute myocardial infarction, preexisting severe left heart valve disease or systolic dysfunction. Clinical, paraclinical, and echocardiography data were documented. The primary outcome was a composite of in-hospital mortality, prolonged hospital stay, and prolonged ICU stay. Results: A total of 128 septic patients were included, with a median age of 72.5 years and a 55% male proportion. Alcohol abuse, vasopressor therapy and orotracheal intubation on admission were risk factors for developing SICD. More than a third developed SICD (37%). We identified four different types of cardiac dysfunction based on echocardiography. An NT-proBNP level of over 9000 pg/mL was a predictor of SICD, composite outcome and mortality. A total of 56 patients (44%) experienced in-hospital mortality. Even though the occurrence of SICD did not predict mortality, it was a significant predictor of the composite outcome. Conclusions: This study describes the incidence and spectrum of SICD in a group of septic patients admitted to a tertiary care hospital. The occurrence of any type of cardiac dysfunction associated with sepsis and high NT-proBNP levels had strong prognostic implications. Full article

Nasotracheal Intubation (NTI) is a common route of airway management in many situations. Over the years, numerous techniques and approaches have been described in performing NTI safely and effectively, including many innovative techniques being published in recent years. However, there hasn’t been a summary of the recent approaches to NTI, especially in an easy, clinically applicable decision making format. In fact, the last algorithmic approach to nasal intubation in the literature was published in 2008. This comprehensive review details an updated analysis of NTI techniques along with a new adapted algorithmic outline to approach NTI in a methodical and stepwise manner. There is also an extensive review of techniques to control epistaxis, which is the most commonly encountered complication during NTI. The newly adapted NTI algorithm simplifies the initial approach to three options: Routine Asleep NTI, Awake NTI, and an Initial Orotracheal Intubation (OTI) followed by Conversion to NTI. Older techniques, such as blind NTI, flexible intubation scope guided, “look before you leap” approach and cuff inflation technique, are discussed along with incorporation of newer techniques, such as videolaryngoscope guided, hybrid, alignment approach, and OTI to NTI conversion. Uniquely, this manuscript reviews all published techniques for converting OTI to NTI and categorizes them into two pathways: direct conversion (with glottic visualization) or indirect conversion (without glottic visualization). Furthermore, original animated videos have been created and attached to help elucidate these conversion techniques visually. Full article

Coinfection with HIV, active tuberculosis, and COVID-19 is rare but markedly increases mortality risk and complicates treatment due to the interactions between these infections. Management requires a multidisciplinary approach that integrates antiretroviral therapy, antituberculous drugs, antibiotics, and supportive care for COVID-19. We report the case of a 28-year-old male with HIV (viral load 30 copies, CD4 count 303), active tuberculosis, and a history of resolved syphilis, who presented with severe respiratory decompensation and hypoxemia (SpO₂ 55%), requiring orotracheal intubation. Initial treatment included broad-spectrum antibiotics, antiretrovirals, and antituberculous therapy. Despite the critical illness, the patient demonstrated progressive clinical improvement, was successfully extubated after a spontaneous breathing trial, and continued recovery under supplemental oxygen. This case underscores the clinical complexity of triple coinfection and highlights the potential for favorable outcomes when management is timely and multidisciplinary. Full article

Background/Objectives: To evaluate the safety and feasibility of continuous positive airway pressure (CPAP) in patients with acute myocardial infarction (AMI) and acute decompensated heart failure (ADHF) during percutaneous coronary intervention (PCI). Non-invasive ventilation (NIV) is an established treatment for ADHF. Methods: All consecutive patients admitted to Santa Croce Hospital of Cuneo, receiving CPAP for ADHF in the cath lab during PCI for AMI, were included in a case series. Results: Between December 2018 and March 2021, 25 pts were included (median age 78 yrs, 48% female), with 64% of patients presenting with ST-elevation AMI and 17 (69%) in cardiogenic shock. At admission median left ventricular ejection fraction was 35 (20–60)% and eight (32%) patients had severe mitral regurgitation. Median PaO₂/FiO₂ was 183 (141–261) mmHg/%, lactate level 2.4 (1.3–3.8) mmol/L, and NTproBNP 7882 (3139–35,000) ng/L. CPAP was positioned and managed by nurses in all cases. Median FiO₂ was 50 (35–100)% and median positive end-expiratory pressure was 7.5 (5–12) cmH₂O. CPAP was generally well tolerated in 22 (88%) patients. One patient suffered cardiac arrest that led to CPAP interruption due to resuscitation maneuvers. No patient required orotracheal intubation in the cath lab. The post-procedural PaO₂/FiO₂ ratio substantially improved to 230 (175–356) mmHg/% (p = 0.007) and lactate decreased to 1.5 (1.0–1) mmol/L (p = 0.002). One patient died during hospital stay due to underlying disease, unrelated to the study procedure. Conclusions: CPAP during PCI in patients with AMI and ADHF seems feasible, safe, and well tolerated. Larger studies are warranted to confirm these results. Full article

Objectives: To investigate the demographic, epidemiological, and medical profiles of hospitalized COVID-19 patients who received dental care, and to identify their main oral health needs. Methods: This retrospective, descriptive cohort study analyzed medical and dental records of patients hospitalized with COVID-19 at a private tertiary hospital in São Paulo, Brazil, from January 2020 to March 2022. The data collected included demographic variables, comorbidities, length of hospitalization, need for respiratory support, clinical outcomes, dental diagnoses, and procedures performed. Results: A total of 129 medical records were reviewed. The sample included 93 males (72%) and 36 females (28%), with a mean age of 72 years. Comorbidities were present in 92% of cases, most frequently a prior COVID-19 infection (59%), diabetes (36%), and depression (31%). The mean hospital stay was 51 days, with a median of 33 days. Most patients (91%) required ICU care; among these, 87% received invasive mechanical ventilation. Dental consultations were most commonly requested for oral assessments (88%), lesions (58%), and opportunistic infections (8%). The most frequent diagnoses were trauma-related lesions from orotracheal intubation (63%), opportunistic infections (45%), and odontogenic or periodontal infections (15%). Primary treatments included oral hygiene procedures (89%), photobiomodulation therapy (67%), and tooth extractions (6%). Patients received an average of eight dental consultations. The overall mortality rate was 26%. Conclusions: Older male patients with COVID-19 frequently required intensive dental care during hospitalization. Oral trauma and opportunistic infections were common, highlighting the need for specialized dental management in critically ill populations. Full article

Plasmodium falciparum malaria remains a major cause of morbidity and mortality, particularly in endemic regions. We report the case of a 21-year-old male with recent travel to an endemic area (Guapi, Colombia), who presented with febrile symptoms, severe respiratory distress, and oxygen saturation below 75%, necessitating orotracheal intubation. During the procedure, he developed pulseless electrical activity cardiac arrest, achieving return of spontaneous circulation after advanced resuscitation. Diagnosis was confirmed by thick blood smear, demonstrating P. falciparum infection. The patient progressed to multiorgan failure, including acute respiratory distress syndrome with capillary leak pulmonary edema, refractory distributive shock, acute kidney injury with severe hyperkalemia, and consumptive thrombocytopenia. Management included invasive mechanical ventilation, vasopressor support, sedation-analgesia, neuromuscular blockade, methylene blue, unsuccessful hemodialysis due to hemorrhagic complications, and platelet transfusions. Despite these interventions, the patient experienced a second cardiac arrest and died. This case highlights the severity and rapid progression of severe malaria with multisystem involvement, underscoring the critical importance of early diagnosis and intensive multidisciplinary management. It also emphasizes the need for preventive strategies for travelers to endemic areas and the development of clinical protocols to improve outcomes in complicated malaria. Full article

Background and Objectives: Metabolic-flow (<0.35 L/min) anesthesia is practiced more often as manufacturers provide newer technologies, yet the benefits of metabolic-flow anesthesia have not been fully investigated. This study aimed to investigate the feasibility and safety of automated gas control (AGC^®) mode, which provides metabolic-flow anesthesia, in a pediatric population. Materials and Methods: Pediatric surgery patients between 1 and 10 years of age were included in this prospective observational trial. After intravenous induction and safe orotracheal intubation, AGC^® was initiated, and total sevoflurane consumption (mL) and wash-in speed-based sevoflurane consumption data were collected to measure feasibility. For safety, inspired (F_iO₂), alveolar (F_AO₂), and expired (F_EO₂) oxygen concentration data, and inspired and alveolar sevoflurane (F_iSevo and F_ASevo, respectively) concentration data, were recorded. Changes in fresh gas flow (FGF) throughout the procedure and postoperative recovery data were also compared. Results: A total of 130 patients were eligible for this study, and 121 patients were included in the analyses; 30 patients had a wash-in speed of 4 (WI4) and 91 patients had a wash-in speed of 8 (WI8) at follow-up. The total mean sevoflurane consumption was 9.35 ± 4.93 mL for a median surgery duration of 100 min. WI8 patients consumed more sevoflurane (9.92 ± 5.08 mL vs. 7.79 ± 4.19 mL, p = 0.04). At the 15th and 30th minutes, the FGF dropped under minimal flow and metabolic flow limits, respectively (p < 0.001). The times to extubation and obeying commands were shorter in WI8 patients (8 (5–10) vs. 11 (5–15) p = 0.03, and 9.5 (5–10.5) vs. 13 (9–17) p < 0.01). Conclusions: Maintenance with AGC^® may offer up to 40 h of anesthesia, considering that the volume of a sevoflurane bottle is 250 mL, reflecting exceptional savings compared to conventional anesthesia management. Metabolic flow anesthesia driven by AGC^® is feasible and safe in pediatric anesthesia practice. Full article

Background and Objectives: Chronic obstructive pulmonary disease (COPD) poses a significant healthcare challenge worldwide, frequently leading to exacerbations necessitating intensive care unit admissions for potentially life-threatening complications. We aimed to investigate correlations between laboratory parameters, bacteriological agents, ventilation mode, and survival rates among COPD patients admitted to the ICU. Materials and Methods: Data were collected from the Pulmonology Department of Mures Clinical County Hospital, Romania, from 1 January 2022 to 30 October 2023. Eighty-four COPD patients required ICU transfer, except for concurrent SARS-CoV-2 infections. Results: Ventilation modes exhibited a significant correlation with specific bacteriological agents, orotracheal intubation being more prevalent in infections with Acinetobacter baumanii, Staphylococcus aureus, and Streptococcus pneumoniae (p < 0.001). Negative cultures were predominantly found in patients managed with non-invasive ventilation. Laboratory parameters revealed an association between elevated white blood cell counts and bacteriological superinfection, particularly with Escherichia coli (p < 0.001). Different bacteriological agents had different survival rates. Patients infected with Acinetobacter baumanii exhibited the highest mortality rate, while those with Staphylococcus aureus had the lowest (p < 0.01). Conclusions: The importance of prompt evaluation of laboratory parameters and bacteriological findings is underscored by these findings, particularly in ICU settings where ventilation and bacteriological profiles influence patient outcomes. The identification of elevated WBC counts is a marker of bacterial superinfection. The association between specific bacterial agents and ventilation modes highlights the importance of tailored treatment based on microbial profiles. These insights can be applied to refine treatment protocols and enhance survival rates in severe COPD exacerbations that require ICU management. Full article

Background/Objectives: Critical lung infection affects alveolar cells and probably also their ability to perform surfactant procedures, but bedside tools for monitoring lung surfactants are lacking. In this descriptive exploratory study, we aimed to evaluate lung surfactant levels in bronchial aspirate (BA) from patients admitted to the intensive care unit due to severe respiratory failure. Methods: Bronchial aspirates were collected from nine patients (median age: 72 years, range: 52–85) who required orotracheal intubation. Samples were obtained within 24 h of mechanical ventilation initiation (T1), after three days on a ventilator (T2), and on day seven (T3) for four patients. The concentration of dipalmitoylphosphatidylcholine (DPPC), a key surfactant component, was assessed in the lamellar body precipitate. Results: Across the nine patients at T1, the DPPC level was 12 µM (range: 3–20 µM). By T2, the DPPC level declined to 8 µM (range: 2–22 µM), with a statistically significant decrease from T1 (p = 0.0039). At T3, the DPPC level in four patients ranged from 2 to 5 µM, though the difference from T2 was not statistically significant. A surfactant biomarker would assist clinical decision-making when dealing with patients in severe respiratory failure where exogenous surfactant therapy may be considered. Conclusions: DPPC levels obtained from bronchial aspirate can be measured in patients with severe respiratory failure and may serve as a useful biomarker for lung surfactant status, which suggests the potential for bedside assessment in clinical practice with a dedicated test device. Full article