Search Results (389)

Background/Objectives: Fluid overload in critically ill patients is linked to adverse outcomes. While resuscitation strategies are well established, guidance for the de-resuscitation phase remains limited. This study aimed to identify clinical factors associated with diuretic response and achieving negative fluid balance (FB) in critically ill patients. Methods: We conducted a single-center, retrospective cohort study of ICU patients who received intravenous furosemide between 2017 and 2023. A CHAID (Chi-square Automatic Interaction Detector) decision tree identified clinical variables associated with fluid removal after the first dose, and a mixed-effects model analyzed repeated measurements. Results: The cohort comprised 1764 patients over 6632 ICU days. Mean arterial pressure (MAP) was the strongest predictor of negative FB. MAP ≤ 75 mmHg yielded minimal negative FB (−33 ± 1054 mL/24 h); MAP 75–90 mmHg yielded intermediate negative FB (−467 ± 1140 mL/24 h); and MAP > 90 mmHg produced the greatest negative FB (−899 ± 1415 mL/24 h; p < 0.001). Secondary associations varied by MAP: creatinine at low MAP, blood urea nitrogen at mid-range MAP, and SOFA score at high MAP, all inversely related to negative FB. In mixed-effects analyses, each 1 mmHg MAP increase was associated with 23.3 mL greater fluid removal (p < 0.001). Independent factors linked to reduced negative FB included vasopressor use (noradrenaline), elevated creatinine, and higher SOFA scores. Conclusions: In this cohort, MAP was significantly associated with the likelihood of achieving a negative fluid balance during de-resuscitation. Conversely, vasopressor use, renal dysfunction, and higher illness severity were linked to reduced diuretic responsiveness. These findings support individualized de-resuscitation strategies. Full article

Background: Accurate risk stratification in acute pulmonary embolism (PE) is critical for guiding management. This study assessed the prognostic value of computed tomography (CT) indicators of right-heart strain and thrombus burden for predicting in-hospital adverse events. Methods: In this retrospective cohort of 300 patients with CT-confirmed acute PE, the right-to-left ventricular (RV/LV) diameter ratio, Pulmonary Artery Obstruction Index (PAOI), and inferior vena cava (IVC) contrast reflux were measured. The primary endpoint was in-hospital adverse events, including hemodynamic collapse, vasopressor or ventilatory support, rescue reperfusion therapy, or death. Logistic regression and receiver operating characteristic (ROC) analyses were performed. Results: Adverse events occurred in 106 patients (35.3%). Compared with stable patients, those with events had higher RV/LV ratios (1.45 vs. 1.03), higher PAOI (38.8 vs. 24.3), and more frequent IVC reflux (74% vs. 7%) (all p < 0.001). Independent predictors were RV/LV ratio (aOR 3.22 per 0.1), PAOI (aOR 5.53 per 10 points), and IVC reflux (aOR 428.5; all p < 0.001). The model showed excellent discrimination (AUC = 0.96). Conclusions: CT-derived indices of right-heart strain and thrombus burden are strong, independent predictors of in-hospital adverse events in acute PE and should be integrated into routine CT-based risk assessment. Full article

Background: Pre-eclampsia causes endothelial dysfunction and altered vascular reactivity, which may increase perioperative risk, particularly under the physiologic stress of general anesthesia (GA). However, the evidence regarding its independent effects under uniform GA conditions is limited. This study assessed the association between pre-eclampsia and intraoperative hemodynamic stability as well as postoperative complications in women undergoing cesarean section under GA. Methods: This retrospective cohort study screened 1242 women who underwent GA for cesarean delivery between January 2017 and July 2024. After applying exclusion criteria, 959 patients were included: 169 with and 790 without pre-eclampsia. The intraoperative blood-pressure and heart-rate trends, vasopressor use, operative variables, and postoperative complications were analyzed. Predictors of postoperative respiratory complications were identified using logistic regression with Firth correction. Results: Patients with pre-eclampsia showed consistently higher mean arterial pressures throughout induction and emergence, whereas trends in heart rate were similar. Postoperative morbidity was higher in the pre-eclampsia group (11.8% vs. 5.3%), with increased respiratory complications (3.6% vs. 1.1%) and longer hospital stays. Pre-eclampsia independently predicted postoperative respiratory complications in univariable (odds ratio [OR] 3.27, 95% confidence interval [CI] 1.13–8.90, p = 0.03), multivariable (OR 3.13, 95% CI 1.09–8.98, p = 0.03), and Firth’s analyses (OR 3.21, 95% CI 1.11–8.77, p = 0.03). Conclusions: Pre-eclampsia was associated with persistent intraoperative hypertension and higher risks of postoperative respiratory morbidity under GA. These findings support the need for individualized hemodynamic control, cautious fluid management, and increased postoperative respiratory surveillance in patients with pre-eclampsia. Full article

Biventricular Takotsubo cardiomyopathy (TCM) is a rare variant characterized by involvement of both the left and right ventricles. This variant is associated with greater hemodynamic instability and longer hospital stays compared to the isolated left ventricular-only variant. We report the case of a 67-year-old female patient who underwent elective resection of a left adrenal adenoma. While her preoperative and intraoperative courses were uneventful, she developed cardiogenic shock postoperatively, necessitating prolonged intensive care unit (ICU) management and vasopressor support. Further evaluation revealed elevated high-sensitivity troponin levels and reduced ejection fraction on echocardiography (30–35%). Hypokinesis was noted in the apical and mid-ventricular segments of both ventricles. A coronary angiogram performed two months prior to admission showed no significant coronary artery disease. Based on these findings, a diagnosis of biventricular TCM was established. The patient was managed supportively and discharged in stable condition with ongoing therapy, including beta-blockers, renin–angiotensin–aldosterone system inhibitors (RAASis), and statins. Follow-up echocardiography showed resolution of regional wall motion abnormalities. Although rare, biventricular TCM is associated with increased severity and a higher risk of complications. Early recognition and timely management are essential to improve outcomes in affected patients. Full article

Background: Left lateral tilt is traditionally recommended during cesarean delivery to reduce aortocaval compression and maintain maternal hemodynamic stability; however, with the widespread adoption of prophylactic vasopressor strategies recommended by current guidelines, the incremental benefit of routine tilt remains uncertain. Methods: We conducted a prospective, nonrandomized observational comparative study at the University Hospital Bratislava including 99 women undergoing elective cesarean delivery under spinal anesthesia. Participants were managed either with a standard ~15° left lateral tilt (n = 41) or in a flat supine position without tilt (n = 58), according to the day of surgery and routine anesthesiologist practice; all other anesthetic and surgical procedures were identical. A prophylactic norepinephrine infusion was initiated at 0.05 µg/kg/min and titrated to maintain systolic arterial pressure at 90–100% of baseline. The primary outcome was the average norepinephrine infusion rate (µg/kg/min) from induction of spinal anesthesia to neonatal delivery. Secondary outcomes included total norepinephrine dose to delivery, dose normalized per kilogram, and neonatal outcomes (Apgar scores and umbilical arterial blood gas parameters). Results: The median norepinephrine infusion rate was 0.03 µg/kg/min in both groups (tilt: IQR 0.01–0.04 vs. no-tilt: IQR 0.02–0.04; p = 0.325). Total norepinephrine dose to delivery (20 [15–35] µg; p = 0.89) and dose per kilogram (0.25 [0.15–0.33] µg/kg vs. 0.34 [0.17–0.44] µg/kg; p = 0.10) were also comparable. Neonatal outcomes, including Apgar scores and umbilical arterial blood gas parameters, did not differ significantly between groups. In a multivariable regression sensitivity analysis adjusting for maternal and procedural covariates, table tilt was not independently associated with norepinephrine requirements. Conclusions: In parturients undergoing cesarean delivery under spinal anesthesia with prophylactic norepinephrine infusion, a 15° left lateral tilt did not reduce vasopressor requirements or improve neonatal outcomes. Routine maternal tilt therefore appears unnecessary for hemodynamic optimization in this setting, and patient positioning can be individualized without compromising maternal or neonatal safety. Full article

Hepatic abscesses are uncommon in dogs and typically develop secondary to biliary tract disease or ascending bacterial infections. Although congenital extrahepatic portosystemic shunt (EHPSS) is known to impair hepatic perfusion and immune clearance, its potential role in predisposing geriatric dogs to hepatic abscess formation has not been previously reported. This case report describes the diagnostic approach, therapeutic decision-making, and clinical outcome of a geriatric dog in which a multidrug-resistant hepatic abscess occurred in association with congenital EHPSS, and to propose a pathophysiologic link between chronic portal hypoperfusion and intrahepatic infection. An 11-year-old neutered male Maltese dog with a known EHPSS presented with acute anorexia and lethargy. Diagnostic imaging revealed a hepatic abscess adjacent to the gallbladder, and cytology confirmed a septic process. Despite targeted meropenem therapy based on antimicrobial susceptibility testing, the abscess failed to regress and C-reactive protein levels continued to rise. Concern for persistent biliary contamination and impaired hepatic immune clearance led to surgical intervention. A combined procedure—partial hepatic lobectomy, cholecystectomy, and shunt attenuation—was performed. Postoperative hypotension was managed successfully with vasopressors and transfusion. The patient recovered uneventfully, and at four-month follow-up, hepatic enzyme activities normalized and liver size increased. These findings highlight the need to evaluate hepatic infections in dogs with EHPSS as a potential consequence of impaired hepatic immune clearance rather than an incidental finding. Full article

Background/Objectives: Advances in pediatric oncology have improved survival; however, critically ill children with cancer remain at high risk for adverse outcomes and frequently require admission to the pediatric intensive care unit (PICU). Despite the rising burden of pediatric cancer in Saudi Arabia, data on PICU utilization and outcomes remain limited. This study aimed to describe the clinical characteristics, critical care interventions, and outcomes of pediatric oncology patients admitted to a tertiary PICU and to identify predictors of mortality. Methods: This is a retrospective cohort study was conducted including pediatric oncology patients (<14 years) admitted to the PICU at King Abdullah Specialized Children’s Hospital, Riyadh, between 2015 and 2021. Demographic, oncologic, and clinical variables; admission indications; PRISM-IV scores; and PICU interventions were collected. Predictors of mortality were evaluated using Cox proportional hazards modeling. Results: A total of 126 pediatric oncology patients were admitted to the PICU during the study period. The median age was 6 years (IQR 3–11), and 59% were female. Hematologic malignancies accounted for 63% of admissions. Sepsis (41%) and respiratory failure (21%) were the leading indications for PICU admission. Comorbidities were present in 33% of patients, and 70% had received prior therapeutic interventions, most commonly chemotherapy. Organ dysfunction occurred in 39% of patients, including 32% with multiorgan failure. Mechanical ventilation was required in 35% of patients, vasopressor support in 30%, and dialysis in a smaller proportion. The overall mortality rate was 19%, with more than half of deaths occurring during the PICU stay. Non-survivors had higher rates of comorbidities and invasive organ support, and higher PRISM scores. Mechanical ventilation (HR 3.02; 95% CI 1.16–7.60) and prior therapeutic interventions (HR 3.19; 95% CI 1.24–8.19) were independent predictors of mortality. Conclusions: Pediatric oncology patients admitted to the PICU experience substantial morbidity and mortality, underscoring the need for early risk identification and optimized supportive care. Full article

Background: Accurate prediction of survival in septic patients remains a major challenge in intensive care medicine. Established severity scores such as the Acute Physiology and Chronic Health Evaluation II (APACHE II) and the Sequential Organ Failure Assessment (SOFA) are widely used to estimate prognosis, while biochemical markers such as serum lactate may provide complementary information. However, the prognostic interplay between these scores, lactate dynamics, vasopressor requirement, and infection focus has not been fully elucidated in septic populations. Methods: We conducted a retrospective observational study of 146 adult patients with sepsis admitted to the intensive care unit (ICU) of the Hospital Clínico Universitario de Valladolid (HCUV), Spain, between 2022 and 2024. Demographic data, APACHE II and SOFA scores at admission, lactate levels at admission and 24 h, albumin, and procalcitonin were recorded. Vasopressor use (categorized by intensity) and infection focus (urinary vs. non-urinary) were documented. The primary outcome was ICU mortality. Correlation analyses (Pearson or Spearman as appropriate) were performed separately for urinary and non-urinary subgroups. Multivariable logistic regression models were constructed using APACHE II, SOFA, log-transformed lactate at 24 h, vasopressor use, and urinary focus as predictors. Model performance was assessed using Nagelkerke R², area under the ROC curve (AUC), and classification accuracy. Results: ICU mortality was 23.3%. APACHE II (OR 1.092; p = 0.004) and SOFA (OR 1.185; p = 0.023) were independent predictors of ICU mortality, while log-transformed lactate at 24 h showed a positive trend (OR 1.920; p = 0.066). The addition of urinary focus (protective effect, OR 0.19; p = 0.035) and vasopressor requirement (OR 2.20; p = 0.04) modestly improved model discrimination (Nagelkerke R² = 0.395). ROC analyses showed AUCs of 0.800 for APACHE + SOFA + log-lactate, 0.824 for the vasopressor model, and 0.833 for the urinary focus model. The best-performing models achieved >85% overall accuracy, with specificity consistently above 95%. Conclusions: In septic ICU patients, APACHE II and SOFA scores remain independent predictors of ICU mortality, and lactate at 24 h adds prognostic value—particularly in non-urinary infections. Vasopressor requirement and infection focus modestly improved model discrimination, underscoring their clinical relevance. These findings suggest that integrating severity scores with selected metabolic and clinical variables may modestly refine survival prediction in septic patients. Full article

Background/Objectives: Spinal anesthesia (SA) for cesarean section and epidural analgesia (EA) for vaginal delivery induce hemodynamic changes that may compromise maternal and fetal safety. In this observational, hypothesis-generating study, we used impedance cardiography (ICG) to characterize maternal hemodynamic responses to EA for labor versus SA for cesarean delivery and to describe hemodynamic profiles associated with commonly used local anesthetic and vasopressor regimens. Methods: In this observational study, 132 women at term were included (52 with epidural analgesia (EA), 80 with spinal anesthesia (SA)). Hemodynamic parameters were measured using the ICON electrical cardiometry monitor (Osypka Medical GmbH). ICON and oscillometric blood pressure (BP) monitoring captured cardiac index (CI), stroke volume (SV), heart rate (HR), systemic vascular resistance index (SVRI), and thoracic fluid content (TFC) at T0 (baseline), approximately 5 and approximately 10 min, skin incision, delivery, and oxytocin administration. Results: CI remained stable and comparable between EA and SA (3.9 ± 0.6 vs. 3.9 ± 0.6 L/min/m²; p = 0.530). SV was higher in EA (85.1 ± 11.3 vs. 78.1 ± 9.7 mL; p < 0.001), whereas HR was higher in SA (92.2 ± 12.9 vs. 85.8 ± 12.5 bpm; p = 0.009). In EA, ropivacaine and bupivacaine showed similar hemodynamic profiles. Within the SA cohort, women managed with phenylephrine infusion had lower CI and HR but higher MAP and SVRI compared with those receiving ephedrine boluses, consistent with the expected pharmacodynamic profiles of these agents. Conclusions: ICG was feasible and provided dynamic, noninvasive estimates of maternal cardiovascular adaptation during obstetric anesthesia. In this non-randomized, exploratory cohort, descriptive differences in hemodynamic profiles between vasopressor strategies were more pronounced than between local anesthetics. Phenylephrine-based management showed a pattern of higher BP and SVRI but lower CI and HR, whereas ephedrine-based management tended to preserve CI through chronotropic effects. Full article

Background: Septic shock remains a critical challenge with high mortality, particularly in refractory cases requiring high doses of vasopressors. Hemoadsorption with the oXiris^® membrane, capable of simultaneously removing endotoxins, cytokines, and damage-associated molecular patterns (DAMPs), represents a personalized therapeutic strategy targeting the underlying pathophysiology. However, clinical evidence on its impact remains limited and lacks consensus. This study aims to analyze the effects of oXiris^® therapy on hemodynamic, inflammatory, and perfusion parameters in a real-world cohort of patients with septic shock. Methods: We conducted a retrospective cohort study in a surgical Intensive Care Unit (ICU) at a tertiary hospital, including 45 adult patients with septic shock treated with continuous renal replacement therapy using the oXiris^® membrane for at least 48 h. The institutional protocol involved filter changes at least every 24 h during the first 48 h of therapy. Hemodynamic variables, vasopressor doses, and biochemical markers were collected at baseline (T0), 24 h (T1), and 48 h (T2). The primary objective was to describe the evolution of these parameters. Secondary objectives included analysis of 30-day mortality and identification of prognostic factors. Results: The cohort consisted of 45 patients (80.0% male, median age 71 years), with a predominance of abdominal infectious focus (71.1%). A significant reduction in median norepinephrine requirements was observed from T0 to T2 (p < 0.00001), along with a significant increase in mean arterial pressure (MAP) (p < 0.00001). Key markers of perfusion and inflammation also improved, with a significant decrease in arterial lactate (p < 0.00001) and procalcitonin (p = 0.00082) at 48 h. No significant changes were observed in the Sequential Organ Failure Assessment (SOFA) score. The observed mortality rate in the ICU was 31.1%, lower than the median predicted mortality by Simplified Acute Physiology Score II (SAPS II) (37%). Baseline Charlson Comorbidity Index (CCI), creatinine, arterial lactate, and SOFA score were independent predictors of mortality. Conclusions: In this cohort of septic shock patients, therapy with oXiris^®, applied with a frequent filter exchange protocol, was associated with a significant reduction in vasopressor requirements and an improvement in key hemodynamic, perfusion, and inflammatory markers. The observed ICU mortality was lower than predicted by severity scores. These findings support the role of oXiris^® as a personalized adjuvant therapy in specific septic shock phenotypes and underscore the need for prospective randomized trials to confirm these benefits. 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

Blood pressure (BP) monitoring is essential in managing critically ill patients in the intensive care unit (ICU), particularly for ensuring adequate end-organ perfusion in hypotensive states. Invasive arterial catheters and noninvasive oscillometric cuffs are often used together, but discrepancies between the two methods are common. These differences can arise from technical factors (e.g., transducer leveling, cuff size and placement, arterial waveform damping) as well as patient-related factors (e.g., vasoconstriction, arrhythmias, altered arterial compliance). This creates a clinical dilemma: which measurement best reflects the patient’s true perfusion pressure, and how should management be guided? This review offers a practical approach for addressing discrepancies between invasive and noninvasive BP measurements in adult hypotensive ICU patients, including those with shock requiring vasopressor support. Based on contemporary data, we propose that a difference greater than 10 mmHg in mean arterial pressure (MAP) between the two methods can serve as a pragmatic threshold to trigger structured evaluation, rather than a universal definition of clinical significance. MAP is prioritized as the key variable for assessing perfusion pressure. When a discrepancy is detected, clinicians are encouraged to integrate both measurements with clinical signs of hypoperfusion and to perform a systematic assessment of technical and physiologic contributors before deciding which value should guide treatment. We present a stepwise clinical decision-making algorithm that helps practitioners (1) recognize when a discrepancy is large enough to matter, (2) evaluate perfusion using bedside and laboratory markers, (3) identify technical or anatomic reasons for discordant readings, and (4) determine when more central arterial monitoring may be appropriate. By structuring the evaluation of discordant BP measurements, this approach aims to reduce the risk of unrecognized hypotension or overtreatment, support more consistent hemodynamic decision-making, and ultimately improve the management of critically ill, hypotensive patients. Full article

Levosimendan, a calcium-sensitizing inodilator, has emerged as a promising adjunctive therapy in patients undergoing veno-arterial extracorporeal membrane oxygenation (V-A ECMO). Its pharmacodynamic profile, combining positive inotropy with vasodilation and mitochondrial protective effects, offers a unique therapeutic potential in the context of mechanical circulatory support. Despite growing interest, the clinical impact of Levosimendan in ECMO remains debated, with heterogeneous evidence regarding its efficacy in improving weaning success, reducing vasopressor requirements or mitigating ischemia-reperfusion injury. This narrative review aims to critically appraise the current literature on Levosimendan use in ECMO settings, exploring its mechanistic rationale, pharmacologic behavior under extracorporeal circulation and potential role in various clinical scenarios including post-cardiotomy shock and refractory cardiogenic failure. The limitations of existing studies are critically examined, underscoring the need for high-quality clinical trials to define appropriate patient selection, optimal timing of administration and dosing strategies. This review synthesizes current evidence to determine whether Levosimendan constitutes a true therapeutic asset or remains merely an adjunctive agent in the complex management of ECMO supported patients. Full article

Background/Objectives: The relationship between body mass index (BMI) and clinical outcomes in sepsis patients remains controversial, with some studies suggesting an “obesity paradox” and others indicating increased risks for underweight individuals. This study aims to further explore the impact of BMI on mortality and other specific sepsis outcomes. Methods: This was a retrospective cohort study of adult patients with sepsis admitted to the intensive care unit (ICU) from 1 January 2021 to 31 December 2023. Patients were divided into four groups according to BMI category. The primary outcome of this study was ICU mortality. Secondary outcomes included the development of septic shock, acute respiratory distress syndrome, 30- and 90-day mortality, ICU and hospital length of stay, and vasopressor- and/or ventilation-free days. Results: A total of 559 patients were included in the study. Among these, 51 were in the underweight group, 206 were in the normal weight group, 158 were in the overweight group, and 184 were in the obese group. The primary outcome of ICU mortality was not significantly different among all BMI groups (p-value > 0.05). Similarly, all secondary outcomes were not significantly different between the groups. Conclusions: Our findings demonstrate that BMI in sepsis patients is not associated with worse clinical outcomes. Further prospective research is warranted to confirm these findings on a larger scale. Full article

Background/Objectives: Sepsis-associated liver injury (SALI) is a critical and often early complication of sepsis, defined by distinct hyper-inflammatory and immunosuppressive phases that shape patient phenotypes. Methods: Characterizing these phases establishes a foundation for immunomodulation strategies tailored to individual immune responses, as discussed subsequently. Results: The initial inflammatory response activates pathways such as NF-κB and the NLRP3 inflammasome, leading to a cytokine storm that damages hepatocytes and is frequently associated with higher SOFA scores and a higher risk of 28-day mortality. Kupffer cells and infiltrating neutrophils exacerbate hepatic injury by releasing proinflammatory cytokines and reactive oxygen species, thereby causing cellular damage and prolonging ICU stays. During the subsequent immunosuppressive phase, impaired infection control and tissue repair can result in recurrent hospital-acquired infections and a poorer prognosis. Concurrently, hepatocytes undergo significant metabolic disturbances, notably impaired fatty acid oxidation due to downregulation of transcription factors such as PPARα and HNF4α. This metabolic alteration corresponds with worsening liver function tests, which may reflect the severity of liver failure in clinical practice. Mitochondrial dysfunction, driven by oxidative stress and defective autophagic quality control, impairs cellular energy production and induces hepatocyte death, which is closely linked to declining liver function and increased mortality. The gut-liver axis plays a central role in SALI pathogenesis, as sepsis-induced gut dysbiosis and increased intestinal permeability allow bacterial products, including lipopolysaccharides, to enter the portal circulation and further inflame the liver. This process is associated with sepsis-related liver failure and greater reliance on vasopressor support. Protective microbial metabolites, such as indole-3-propionic acid (IPA), decrease significantly during sepsis, removing key anti-inflammatory signals and potentially prolonging recovery. Clinically, SALI most commonly presents as septic cholestasis with elevated bilirubin and mild transaminase changes, although conventional liver function tests are insufficiently sensitive for early detection. Novel biomarkers, including protein panels and non-coding RNAs, as well as dynamic liver function tests such as LiMAx (currently in phase II diagnostics) and ICG-PDR, offer promise for improved diagnosis and prognostication. Specifying the developmental stage of these biomarkers, such as identifying LiMAx as phase II, informs investment priorities and translational readiness. Current management is primarily supportive, emphasizing infection control and organ support. Investigational therapies include immunomodulation tailored to immune phenotypes, metabolic and mitochondrial-targeted agents such as pemafibrate and dichloroacetate, and interventions to restore gut microbiota balance, including probiotics and fecal microbiota transplantation. However, translational challenges remain due to limitations of animal models and patient heterogeneity. Conclusion: Future research should focus on developing representative models, validating biomarkers, and conducting clinical trials to enable personalized therapies that modulate inflammation, restore metabolism, and repair the gut-liver axis, with the goal of improving outcomes in SALI. Full article