Search Results (1,446)

Background: Diabetes mellitus is associated with worse outcomes after cardiac arrest. Hyperglycemia, diabetes treatments and other long-term sequalae may contribute to this association. We sought to determine the acute effect of diabetes on the return of spontaneous circulation (ROSC) and post-arrest cardiac function in a rat cardiac arrest model. Methods: Eighteen male Wistar rats were utilized, and 12 underwent the induction of type II diabetes for 10 weeks through a high-fat diet and the injection of streptozotocin. The carotid artery flow and femoral arterial pressure were measured. Seven minutes of asphyxial cardiac arrest was induced. An external cardiac compression was performed via an automated piston. Post-ROSC, epinephrine was titrated to a mean arterial pressure (MAP) of 70 mmHg. Data was analyzed using the Mann–Whitney test. The significance was set at p ≤ 0.05. Results: The rate of the ROSC was significantly lower in animals with diabetes, 50% compared to 100% in non-diabetics. Additionally, it took significantly longer to achieve the ROSC in diabetics, p = 0.034. In animals who survived, the cardiac function was reduced, as indicated by an increased epinephrine requirement, p = 0.041, and a decreased cardiac output at the end of the experiment, p = 0.017. The lactate, venous and arterial pressures, heart rate and carotid flow did not differ between groups at 2 h. Conclusions: Diabetes negatively affects the survival from cardiac arrest. Here, the critical difference was the rate of the conversion to a life-sustaining rhythm and the achievement of the ROSC. The post-ROSC cardiac function was depressed in diabetic animals. Interventions targeted at improving defibrillation success may be important in diabetics. Full article

In the trauma resuscitation literature, there are inconsistent definitions of what constitutes massive transfusion and a unit of blood, complicating the use of transfusion cut-points to declare futility. This is problematic as it can lead to the inefficient use of blood products, further exacerbating current blood product shortages. Previous studies have used various transfusion cut-points per hour to define futility in retrospective analyses but have not accurately defined futility at the bedside due to patient survival even at large rates and volumes of blood transfused. In an attempt to use transfusion cut-points as a marker to help define futility, guidelines have been proposed to limit blood product waste in transfusions for severely bleeding trauma patients, such as Suspension of Transfusion and Other Procedures (STOP) for patients older than 15 and the Futility of Resuscitation Measure (FoRM), used to determine futility in patients older than 60. In an effort to construct effective bedside futile resuscitation criteria with 100% positive predictive value and specificity, this review proposes the use of specific blood component transfusion cut-points combined with parameters from both STOP and FoRM to allow for a comprehensive and accurate method of declaring futility in severely bleeding trauma patients. Full article

After the first release of synthalin B (dodecamethylenbiguanide) in 1928 and its later retraction in the 1940s in Germany, the retraction of phenformin (N-Phenethylbiguanide) and of Buformin in the USA (but not outside) because of the lethal complication of acidosis seemed to have put an end to the era of the biguanides as oral antidiabetics. The strongly hygroscopic metformin (1-1-dimethylbiguanide), first synthesized 1922 and resuscitated as an oral antidiabetic (type 2 of the elderly) compound first released in 1959 in France and in other European countries, was used in the first large multicenter prospective long-term trial in England in the UKPDS (1977–1997). It was then released in the USA after a short-term prospective trial in healthy overweight “young” type 2 diabetics (mean age 53 years) in 1995 for oral treatment of type 2 diabetes. It was, however, prescribed to mostly multimorbid older patients (above 60–65 years of age). Metformin is now the most used oral drug for type 2 diabetes worldwide. While intravenous administration of biguanides does not have any glucose-lowering effect, their oral administration leads to enormous increase in their intestinal concentration (up to 300-fold compared to that measured in the blood), to reduced absorption of glucose from the diet, to increased excretion of glucose through the stool, and to decrease in insulin serum level through increased hepatic uptake and decreased production. Intravenously injected F18-labeled glucose in metformin-treated type 2 diabetics accumulates in the small and even more in the large intestine. The densitometry picture observed in metformin-treated overweight diabetics is like that observed in patients after bowel-cleansing or chronically taking different types of laxatives, where the accumulated radioactivity can even reach values observed in colon cancer. The glucose-lowering mechanism of action of metformin is therefore not only due to inhibition of glucose uptake in the small intestine but also to “attraction” of glucose from the hepatocyte into the intestine, possibly through the insulin-mediated uptake in the hepatocyte and its secretion into the bile. Furthermore, these compounds have also a diuretic effect (loss of sodium and water in the urine) Acute gastrointestinal side effects accompanied by fluid loss often lead to the drugs’ dose reduction and strongly limit adherence to therapy. Main long-term consequences are “chronic” dehydration, deficiency of vitamin B12 and of iron, and, as observed for all the biguanides, to “chronic” increase in fasting and postprandial lactate plasma level as a laboratory marker of a clinical condition characterized by hypotension, oliguria, adynamia, and evident lactic acidosis. Metformin is not different from the other biguanides: synthalin B, buformin, and phenformin. The mechanism of action of the biguanides as antihyperglycemic substances and their side effects are comparable if not even stronger (abdominal pain, nausea, vomiting, diarrhea, fluid loss) to those of laxatives. Full article

Hemorrhage is the leading cause of preventable death in trauma care, requiring rapid and accurate detection to guide effective interventions. Hemorrhagic shock can be masked by underlying compensatory mechanisms, which may lead to delayed decision-making that can compromise casualty care. In this proof-of-concept study, we aimed to develop and evaluate machine learning models to predict Percent Estimated Blood Loss from a photoplethysmography waveform, offering non-invasive, field deployable solutions. Different model types were tuned and optimized using data captured during a hemorrhage and resuscitation swine study. Through this optimization process, we evaluated different time-lengths of prediction windows, machine learning model architectures, and data normalization approaches. Models were successful at predicting Percent Estimated Blood Loss in blind swine subjects with coefficient of determination values exceeding 0.8. This provides evidence that Percent Estimated Blood Loss can be accurately derived from non-invasive signals, improving its utility for trauma care and casualty triage in the pre-hospital and emergency medicine environment. Full article

Background/Objectives: The SARS-CoV-2 and influenza A (H1N1)pdm09 pandemics have resulted in high numbers of ICU admissions, with high mortality. Identifying risk factors for ICU mortality at the time of admission can help optimize clinical decision making. However, the risk factors identified may differ, depending on the type of analysis used. Our aim is to compare the risk factors and performance of a linear model (multivariable logistic regression, GLM) with a non-linear model (random forest, RF) in a large national cohort. Methods: A retrospective analysis was performed on a multicenter database including 8902 critically ill patients with influenza A (H1N1)pdm09 or COVID-19 admitted to 184 Spanish ICUs. Demographic, clinical, laboratory, and microbiological data from the first 24 h were used. Prediction models were built using GLM and RF. The performance of the GLM was evaluated by area under the ROC curve (AUC), precision, sensitivity, and specificity, while the RF by out-of-bag (OOB) error and accuracy. In addition, in the RF, the im-portance of the variables in terms of accuracy reduction (AR) and Gini index reduction (GI) was determined. Results: Overall mortality in the ICU was 25.8%. Model performance was similar, with AUC = 76% for GLM, and AUC = 75.6% for RF. GLM identified 17 independent risk factors, while RF identified 19 for AR and 23 for GI. Thirteen variables were found to be important in both models. Laboratory variables such as procalcitonin, white blood cells, lactate, or D-dimer levels were not significant in GLM but were significant in RF. On the contrary, acute kidney injury and the presence of Acinetobacter spp. were important variables in the GLM but not in the RF. Conclusions: Although the performance of linear and non-linear models was similar, different risk factors were determined, depending on the model used. This alerts clinicians to the limitations and usefulness of studies limited to a single type of model. Full article

Background: Postoperative pain management after a cesarean section remains a significant challenge, as inadequate control can delay maternal recovery and hinder early bonding and breastfeeding. While multimodal analgesia is the standard approach, non–pharmacological strategies like immediate skin–to–skin contact (SSC) are often underused despite their potential benefits in reducing pain, improving uterine contractions, and increasing maternal satisfaction. Objective: To evaluate the effects of immediate SSC on postoperative pain perception, uterine contraction quality, and maternal satisfaction, and to explore ways to incorporate SSC into routine post–cesarean care to promote recovery and humanized care. Method: A randomized clinical trial was conducted with 80 women undergoing elective cesarean sections, divided into two groups: SSC (40 women) and control (40 women). Postoperative pain was measured using the Visual Analog Scale (VAS) at various intervals, while uterine contraction quality and maternal satisfaction were assessed through clinical observation and a Likert scale, respectively. Results: We found that women in the SSC group experienced significantly lower pain scores (VAS2 and VAS3, p < 0.001), stronger infraumbilical uterine contractions (92.5%, p < 0.001), and higher satisfaction levels (average 9.98 vs. 6.50, p < 0.001). An inverse correlation was observed between pain intensity and satisfaction, indicating that SSC enhances both physiological and psychological recovery. Conclusions: Immediate SSC after cesarean is an effective, humanizing intervention that reduces pain, supports uterine contractions, and boosts maternal satisfaction. These findings advocate for integrating SSC into standard postoperative care, aligning with ethical principles of beneficence and autonomy. Further research with larger samples is necessary to confirm these benefits and facilitate widespread adoption in maternity protocols. Full article

Background/Objectives: Sudden cardiac arrest (SCA) is a major global health concern with high mortality despite advances in resuscitation techniques. Achieving return of spontaneous circulation (ROSC) represents merely the initial step in the extensive rehabilitation journey. This review highlights the critical role of structured, multidisciplinary rehabilitation following ROSC, emphasizing the necessity of integrated physiotherapy, neurocognitive therapy, and psychosocial support to enhance quality of life and societal reintegration in survivors. Methods: This narrative review analyzed peer-reviewed literature from 2020–2025, sourced from databases such as PubMed, Scopus, Web of Science, and Google Scholar. Emphasis was on clinical trials, expert guidelines (e.g., European Resuscitation Council 2021, American Heart Association 2020), and high-impact journals, with systematic thematic analysis across rehabilitation phases. Results: The review confirms rehabilitation as essential in addressing Intensive Care Unit–acquired weakness, cognitive impairment, and post-intensive care syndrome. Early rehabilitation (0–7 days post-ROSC), focusing on parameter-guided mobilization and cognitive stimulation, significantly improves functional outcomes. Structured interdisciplinary interventions encompassing cardiopulmonary, neuromuscular, and cognitive domains effectively mitigate long-term disability, facilitating return to daily activities and employment. However, access disparities and insufficient randomized controlled trials limit evidence-based standardization. Discussion: Optimal recovery after SCA necessitates early and continuous interdisciplinary engagement, tailored to individual physiological and cognitive profiles. Persistent cognitive fatigue, executive dysfunction, and emotional instability remain significant barriers, underscoring the need for holistic and sustained rehabilitative approaches. Conclusions: Comprehensive, individualized rehabilitation following cardiac arrest is not supplementary but fundamental to meaningful recovery. Emphasizing early mobilization, neurocognitive therapy, family involvement, and structured social reintegration pathways is crucial. Addressing healthcare disparities and investing in rigorous randomized trials are imperative to achieving standardized, equitable, and outcome-oriented rehabilitation services globally. Full article

Background: Nemaline myopathy is a rare congenital neuromuscular disease associated with progressive weakness and frequent respiratory complications. In emergency situations, families often serve as the first and only responders. The aim of this study is to explore how parents in Spain care for children with nemaline myopathy during emergency situations, focusing on the clinical responses performed at home and the organizational challenges encountered when interacting with healthcare systems. Methods: A qualitative phenomenological study was conducted with 17 parents from 10 families belonging to the Asociación Yo Nemalínica. Semi-structured interviews were performed via video calls, transcribed verbatim, and analyzed using Giorgi’s descriptive method and ATLAS.ti software (version 24). Methodological rigor was ensured through triangulation, reflexivity, and member validation. Results: Four themes were identified. First, families were described as acting under extreme pressure and in isolation during acute home emergencies, often providing cardiopulmonary resuscitation and respiratory support without professional backup. Second, families managed ambiguous signs of deterioration using clinical judgment and home monitoring tools, often preventing fatal outcomes. Third, parents frequently assumed guiding roles in emergency departments due to a lack of clinician familiarity with the disease, leading to delays or errors. Finally, the transition to the Pediatric Intensive Care Unit was marked by emotional distress and rapid decision-making, with families often participating in critical choices about invasive procedures. These findings underscore the complex, multidisciplinary nature of caregiving. Conclusions: Parents play an active clinical role during emergencies and episodes of deterioration. Their lived experience should be formally integrated into emergency protocols and the continuity of care strategies to improve safety and outcomes. Full article

Extracorporeal cardiopulmonary resuscitation (ECPR) is an established intervention for select patients experiencing refractory cardiac arrest. Among modifiable predictors of survival and neurologic recovery during ECPR implementation, timely restoration of circulation remains critical in the setting of refractory cardiac arrest (CA). The in-hospital cardiac arrest (IHCA) setting is particularly amenable to reducing the low-flow interval through structured system-based design and implementation. Despite increasing utilization of ECPR, the literature remains limited regarding operational standards, quality improvement metrics, and performance evaluation. Establishing operational standards and performance metrics is a critical first step toward systematically reducing low-flow interval duration. In support of this aim, we conducted a comprehensive literature review structured around the Extracorporeal Life Support Organization (ELSO) framework for ECPR implementation. At each step, we synthesized evidence-based best practices and identified operational factors that directly influence time-to-circulation. Our goal is to provide a stepwise evaluation of ECPR initiation to consolidate existing best practices and highlight process components with potential for further study and standardization. We further evaluated the literature surrounding key technical components of ECPR, including cannula selection, placement technique, and positioning. Ongoing research is needed to refine and standardize each stage of the ECPR workflow. Developing optimized, protocol-driven approaches to ensure rapid, high-quality deployment will be essential for improving outcomes with this lifesaving but resource-intensive therapy. Full article

Background/Objective: Sepsis is a leading cause of death in noncoronary intensive care units (ICUs). Fluids for intravascular resuscitation include crystalloids and colloids. There is extensive clinical evidence on colloid use, but large trials comparing gelatine with crystalloid regimens in ICU and septic patients are lacking. This study aimed to determine whether early, protocol-driven volume resuscitation using a gelatine-based regimen achieves hemodynamic stability (HDS) more rapidly than a crystalloid-based regimen in septic patients. Methods: This prospective, controlled, randomised, double-blind, multinational phase IV study compared two parallel groups of septic patients receiving a gelatine-based regimen (Gelaspan^® 4% and Sterofundin^® ISO, B. Braun Melsungen AG each, at a 1:1 ratio) or a crystalloid regimen (Sterofundin^® ISO). Primary endpoint was time to first HDS within 48 h after randomisation. Secondary endpoints included fluid overload, fluid balance, and patient outcomes. Results: 167 patients were randomised. HDS was achieved after 4.7 h in the gelatine group and after 5.8 h in the crystalloid group (p = 0.3716). The gelatine group had a more favourable fluid balance at 24 h (medians: 3463.00 mL vs. 4164.00 mL; p = 0.0395) and less fluid overload (medians: 4296.05 vs. 5218.75%; p = 0.0217). No differences were observed in serious adverse events or mortality. Conclusions: The study provided clinical evidence of balanced gelatine solution for volume resuscitation in septic patients, although it was terminated prematurely. The early and protocol-based administration of gelatine was safe and effective in the enrolled patient population. Time to HDS was not different between groups but the gelatine-based regimen led to better fluid balance and less fluid overload. 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

Fluid resuscitation after thermal injury is paramount to avoid burn shock and restore organ perfusion. Both over- and under-resuscitation can lead to unintended consequences affecting patient outcomes. While many studies have examined systemic effects, limited data exist on how fluid resuscitation impacts burn wound progression in the acute period. Furthermore, the mechanisms underlying burn wound progression remain not fully understood. This study used a swine model to investigate how varying resuscitation levels affect peri-burn wound dynamics. Twenty-seven female Yorkshire pigs were anesthetized, subjected to 40% total body surface area burn and 15% hemorrhage, then randomized (n = 9) to receive decision-support-driven (adequate, 2–4 mL/kg/%TBSA), fluid-withholding (under, <1 mL/kg/%TBSA), or high-constant-rate (over, >>4 mL/kg/%TBSA) resuscitation. Pigs were monitored for 24 h in an intensive care setting prior to necropsy. Laser Doppler Imaging (LDI) was conducted pre-burn and at 2, 6, 12, and 24 h post burn to assess perfusion. Biopsies were taken from burn, peri-burn (within 2 cm), and normal skin. RNA was isolated at 24 h for the qRT-PCR analysis of IL-6, CXCL8, and IFN-γ. At hour 2, LDI revealed increased peri-burn perfusion in over-resuscitated animals vs. under-resuscitated animals (p = 0.0499). At hour 24, IL-6 (p = 0.0220) and IFN-γ (p = 0.0253) were elevated in over-resuscitated peri-burn skin. CXCL8 showed no significant change. TUNEL staining revealed increased apoptosis in over- and under-resuscitated peri-burn skin. Differences in perfusion and cytokine expression based on resuscitation strategy suggest that fluid levels may influence burn wound progression. Full article

Background: Intravascular albumin mass represents the total quantity of albumin circulating within the bloodstream and may serve as a physiologically relevant marker of vascular integrity and fluid distribution in sepsis. While low serum albumin levels are acknowledged as prognostic indicators, dynamic assessments based on albumin mass remain insufficiently explored in patients outside the intensive care unit. Objectives: To describe the temporal changes in intravascular albumin mass in patients with community-acquired sepsis and to examine its relationship with fluid balance and thirty-day mortality. Methods: This prospective observational study encompassed 247 adults diagnosed with community-acquired sepsis who were admitted to a high-dependency hospital ward specializing in acute medical care. The intravascular albumin mass was calculated daily for a duration of up to five days, utilizing plasma albumin concentration and estimated plasma volume derived from anthropometric and hematologic data. Net albumin leakage was defined as the variation in intravascular albumin mass between consecutive days. Fluid administration and urine output were documented to ascertain cumulative fluid balance. Repeated-measures statistical models were employed to evaluate the associations between intravascular albumin mass, fluid balance, and mortality, with adjustments made for age, comorbidity, and clinical severity scores. Results: The intravascular albumin mass exhibited a significant decrease during the initial five days of hospitalization and demonstrated an inverse correlation with the cumulative fluid balance. A greater net leakage of albumin was associated with a positive fluid balance and elevated mortality rates. Furthermore, a reduced intravascular albumin mass independently predicted an increased risk of mortality at thirty days. Conclusions: A reduction in intravascular albumin mass may suggest ineffective fluid retention and the onset of capillary leak syndrome. This parameter holds promise as a clinically valuable, non-invasive indicator for guiding fluid resuscitation in cases of sepsis. Full article

It is critical to provide life-sustaining treatment to OHCA patients before ambulance care arrives. However, incorrectly performed resuscitation maneuvers reduce the chances of survival and recovery for the victims. Therefore, we must train regularly and learn how to do it correctly. To facilitate regular chest compression training, this study aims to improve the accuracy of a chest compression evaluation system using posture estimation and to develop a web application. To analyze and enhance accuracy, the YOLOv8 posture estimation was used to examine compression depth, recoil, and tempo, and its accuracy was compared to that of the manikin, which has evaluation systems. We conducted comparative experiments with different camera angles and heights to optimize the accuracy of the evaluation. The experimental results showed that an angle of 30 degrees and a height of 50 cm produced superior accuracy. For web application development, a system has been designed to allow users to upload videos for analysis and obtain appropriate compression parameters. The usability evaluation of the application confirmed its ease of use and accessibility, and positive feedback was obtained. In the conclusion, these findings suggest that optimizing recording conditions significantly improves the accuracy of posture-based chest compression evaluation. Future work will focus on enhancing real-time feedback functionality and improving the user interface of the web application. Full article

ABG analysis is the gold standard for assessing acid–base balance, oxygenation, and ventilation in critically ill patients, but it is invasive and associated with patient discomfort and potential complications. Venous blood gas (VBG) analysis offers a less invasive alternative, although its clinical utility remains debated. This review evaluates the current evidence on VBG analysis, exploring its correlation with ABG, clinical applications, and limitations. Studies show a strong correlation between ABG and VBG for pH and a good correlation for bicarbonate and base excess in most cases, while the correlation for pCO₂ remains controversial. Predictably, pO₂ values differ significantly due to oxygen consumption gradients between the arterial and venous blood. VBG analysis is especially valuable for initial assessments, monitoring therapeutic responses, and guiding resuscitation in intensive care settings. It is not merely an alternative to ABG but a complementary tool that can provide unique insights, such as mixed venous oxygen saturation (SvO₂) or indices that require combined ABG and VBG data, like the pCO₂ gap. This review highlights the diagnostic equivalence of VBG in appropriate contexts and advocates for its use when arterial sampling is unnecessary or impractical. Furthermore, VBG analysis could enhance patient care by enabling the timely, less invasive assessment of hemodynamic and metabolic conditions. Future research should focus on refining interpretation algorithms and expanding the clinical applications of VBG to fully realize its potential in critical care practice. Full article