Strengths and Weaknesses of Physiotherapy in the Daily Work of an Intensive Care Unit: A Qualitative Study

Objectives: To describe the strengths and barriers of administering a physiotherapy treatment to patients admitted to an intensive care unit. Methods: Qualitative interpretative description study. Twenty-one health professionals working in an intensive care unit in two referral hospitals were recruited in the study. Each personal interview began with open-ended questions and then continued with more interview-inspired questions. All healthcare professionals gave their views on their knowledge, perceptions and observations of the strengths and weaknesses of physiotherapy in the treatment of patients admitted to this unit. Results: The analysis highlighted four main topics: (i) knowledge of the role of physiotherapists at the ICU; (ii) benefits of physiotherapy for patients and in a multidisciplinary team environment; (iii) challenges and proposals for improvement in interprofessional collaboration; iv) needs for the implementation of physiotherapy. Conclusions: This study analyzes the opinion of intensive care unit professionals regarding the strengths and barriers of physiotherapy in these units. Healthcare professionals highlight the importance of early physiotherapy treatment, the insufficient number of physiotherapists in these units and the benefits of physiotherapy in the respiratory and functional improvement of patients. The main perceived barriers are communication between professionals and the need to reduce the ratio of patients per physiotherapist.

Association between Intestinal Flora Metabolites and Coronary Artery Vulnerable Plaque Characteristics in Coronary Heart Disease

Aims/Background The incidence of coronary heart disease (CHD) has been increasing annually. Patients with severe conditions may die from myocardial infarction, heart failure or malignant arrhythmia. Intestinal flora plays an important role in various metabolic processes, such as atherosclerosis, tumour formation, and inflammation. However, its direct role in promoting plaque vulnerability must be further explored and validated. Therefore, this study aims to explore the relationship between changes in intestinal flora, its metabolites in CHD patients and the vulnerability characteristics of coronary plaques. Methods This study recruited 180 subjects, among these, 90 CHD patients diagnosed between January 2023 and January 2024 were selected as the CHD group and 90 healthy volunteers were selected as the control group following a principle of 1:1 ratio. The differences in intestinal flora composition, metabolite levels, and blood biochemical indexes were compared between the two study groups. Based on the coronary angiography (CAG) and intravascular ultrasound (IVUS) results, the CHD group was divided into two sub-groups for stratified comparative analysis: the stable plaque group (n = 49) and the vulnerable plaque group (n = 41). Results The CHD group had reduced intestinal Bifidobacteria and lactic acid bacteria counts and higher intestinal Escherichia coli and Enterococcus levels than the control group (p < 0.05). Moreover, trimethylamine-N-oxide (TMAO) and phenylacetylglutamine (PAGln) levels were significantly higher in the CHD group compared to the control group (p < 0.05). Similarly, the CHD group exhibited substantially elevated serum triglyceride (TG), total cholesterol (TC), and low-density lipoprotein cholesterol (LDL-C) levels compared to the control group. However, compared to the control group, the high-density lipoprotein cholesterol (HDL-C) levels were significantly lower in the CHD group (p < 0.05). Furthermore, the serum levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), serum urea nitrogen (BUN), and serum creatinine (Scr) were comparable in the two experimental groups (p > 0.05). Similarly, intestinal Bifidobacteria, lactic acid bacteria, Escherichia coli, and Enterococcus compositions were comparable in CHD patients with vulnerable plaque and those with stable plaque (p > 0.05). Moreover, CHD patients with vulnerable plaque had elevated TMAO and PAGln levels than those with stable plaque (p < 0.05). However, TG, TC, HDL-C, LDL-C, ALT, AST, BUN, and Scr levels were comparable between CHD patients with a vulnerable plaque and those with stable plaque (p > 0.05). Multivariate regression analysis showed that diabetes, elevated TMAO levels, and elevated PAGln levels were potential risk factors for coronary plaque vulnerability (p < 0.05). Conclusion In summary, CHD patients exhibit significant intestinal flora imbalance, with elevated TMAO and PAGln metabolite levels, which are related to the characteristics of plaque instability.

Comparison of Efficacy and Safety between Two Silver-Containing Dressings in the Treatment of Deep Partial-Thickness Thermal Burns: A Multicenter, Double-Blind, Non-Inferiority, Randomized Clinical Trial

Aims/Background Silver-containing dressings are commonly utilized in burns treatment by virtue of their excellent antibacterial properties. Further research is needed to determine the type of silver-containing dressing that is more effective and safer for burns treatment. Pyperbranched polyamide-Ag dressing (HBPs-Ag dressing) is a modified polyamide dressing with a uniform coating of the Amino-terminated hyperbranched polymer (HBP-NH2)/Ag+ compound on its surface. This study aimed to evaluate the efficacy and safety of a silver ion-containing dressing (HBPs-Ag) for wound contact layer in the treatment of deep partial-thickness burns versus a silver-impregnated tulle dressing (Atrauman Ag). Methods This study was conducted between October 2019 to January 2021 at six sites in China. A total of 132 patients with deep partial-thickness burns (aged 18-65 years, injury occurring within 72 hours, burns <30% total burn surface area) were randomized 1:1 to HBPs-Ag group (study group) or Atrauman Ag group (control group). Data were obtained and analyzed, including total efficacy, wound healing rate, wound healing time, rate of negative bacterial culture from wound secretions, systemic response, skin or tissue irritation, local skin color changes, wound swelling, wound pain and adverse events. Results For partial thickness burns, the HBPs-Ag dressing was not inferior to Atrauman Ag dressing because the total efficiency of HBPs-Ag group (98.3%) was comparable to that of Atrauman Ag group (94.7%) (p > 0.05). There were no significant differences in efficacy, wound healing rate, wound healing time, and rate of negative bacterial culture from wound secretions between the two groups (p > 0.05). There were no statistical differences in all safety indicators tested between the two groups (p > 0.05). Silver was detected in the blood or urine of only 5 patients (3.79%). Conclusion The HBPs-Ag dressing was not inferior to Atrauman Ag dressing in deep partial-thickness burns treatment, with both of them showcasing comparable efficacy and safety. Clinical Trial Registration Chinese Clinical Trial Registry (ChiCTR2100049814).

Modulating oxidative stress: a reliable strategy for coping with community-acquired pneumonia in older adults

Community-acquired pneumonia (CAP) remains one of the leading respiratory diseases worldwide. With the aging of the global population, the morbidity, criticality and mortality rates of CAP in older adults remain high every year. Modulating the signaling pathways that cause the inflammatory response and improve the immune function of patients has become the focus of reducing inflammatory damage in the lungs, especially CAP in older adults. As an important factor that causes the inflammatory response of CAP and affects the immune status of the body, oxidative stress plays an important role in the occurrence, development and treatment of CAP. Furthermore, in older adults with CAP, oxidative stress is closely associated with immune senescence, sarcopenia, frailty, aging, multimorbidity, and polypharmacy. Therefore, multiple perspectives combined with the disease characteristics of older adults with CAP were reviewed to clarify the research progress and application value of modulating oxidative stress in older adults with CAP. Clearly, there is no doubt that targeted modulation of oxidative stress benefits CAP in older adults. However, many challenges and unknowns concerning how to modulate oxidative stress for further practical clinical applications exist, and more targeted research is needed. Moreover, the limitations and challenges of modulating oxidative stress are analyzed with the aim of providing references and ideas for future clinical treatment or further research in older adults with CAP.

β-lactam antibiotics to prevent ventilator-associated pneumonia (VAP) in coma patients: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To evaluate the effect of parenteral β-lactam antibiotics on outcomes related to ventilator-associated pneumonia (VAP) in adult patients in coma due to acute brain injury (ABI).

DESIGN

Systematic review and meta-analysis.

SETTING

Randomized controlled trials (RCTs) published up toSeptember 30, 2024.

PATIENTS OR PARTICIPANTS

Adult patients in coma due to ABI.

INTERVENTIONS

Parenteral β-lactam antibiotics.

MAIN VARIABLES OF INTEREST

Incidence and outcomes related to VAP.

RESULTS

Three RCTs involving 483 patients met inclusion criteria; 231 patients received β-lactam prophylaxis. Among these, there were 115 cases of early-onset VAP (EO-VAP), 49 of late-onset VAP (LO-VAP), and 102 deaths. All studies were conducted in Europe. Causes of coma included trauma, stroke, and CO poisoning. Intravenous β-lactams (ampicillin/sulbactam, cefuroxime, and ceftriaxone) reduced EO-VAP risk by 57% (RR 0.43; 95% CI 0.30-0.61), and all-VAP by 35% (RR 0.65; 95% CI 0.53-0.80). No impact was observed on LO-VAP (RR 0.95; 95% CI 0.54-1.67), 28-day mortality (RR 0.76; 95% CI 0.53-1.09), intubation duration (SMD -0.13; 95% CI -0.46-0.21), or ICU length of stay (SMD -0.22; 95% CI -0.55-0.12). Heterogeneity and the risk of bias were low, with high overall evidence certainty.

CONCLUSIONS

In adult patients in coma due to ABI, intravenous β-lactam antibiotics reduce EO-VAP and all-VAP risk.

The hemodynamic effects of IV paracetamol in intensive care patients

Objective

This retrospective observational study conducted in a general ICU aimed to evaluate the hemodynamic impact of IV paracetamol by monitoring blood pressure, urine output, and core temperature post-administration.

Design

The study was designed as a retrospective observational study in a general ICU setting.

Setting

The study was conducted in a general intensive care unit (ICU).

Patients

Data from 498 patients receiving IV paracetamol in various clinical contexts were analyzed.

Interventions

Patients received IV paracetamol for analgesia and fever reduction as part of their clinical care.

Measurements and main results

The study analyzed the hemodynamic effects of IV paracetamol by monitoring blood pressure, urine output, and core temperature post-administration. A significant decrease in mean systolic and diastolic blood pressure values was observed across different patient subgroups, notably 45-60 min post-infusion. An increase in noradrenaline dosage and a decrease in urine output indicated a decline in end-organ perfusion following IV paracetamol administration. Multivariate analysis identified associations between clinical factors (such as general anesthesia and cardiac conditions) and changes in blood pressure.

Conclusions

While IV paracetamol remains a valuable therapeutic option for pain and fever management, especially in hypertensive patients with specific conditions like traumatic brain injury and cerebral vascular accident, careful monitoring, and individualized dosing strategies are recommended in critically ill patients to maintain hemodynamic stability and optimize clinical outcomes. These findings contribute to enhancing our understanding of IV paracetamol hemodynamic effects and inform evidence-based practices for its use in ICU settings.

Nirmatrelvir/ritonavir prescription and the risk of hospitalization and death in COVID-19 outpatients

OBJECTIVE

The nirmatrelvir/ritonavir is an oral combination of antiviral drugs used to treat the COVID-19. In this study we evaluated the risk of hospitalization and death, comparing COVID-19 patients who received and did not receive ambulatory nirmatrelvir/ritonavir prescription.

MATERIAL AND METHODS

A two-group comparative study was carried out using data from the Mexican Institute of Social Security medical information systems. We analyzed of 83,348 ambulatory patients aged 18 years old and over and with laboratory confirmed SARS-CoV-2 infection during the period from September 12th, 2022, to September 30th, 2023. Of them, 27,437 received nirmatrelvir/ritonavir prescription (32.9%) and 55,911 did not (67.1%). We compared the 60-day COVID-19 related hospitalization and all-cause death risk among groups using a multivariate Poisson regression model.

RESULTS

The 60-day COVID-19 related hospitalization and all-cause death combined incidence was 0.13% in the patients who received nirmatrelvir/ritonavir and 0.26% among the cases who did not receive the prescription. In the multivariate model, after adjusting for age, sex, and previous medical conditions such as chronic kidney disease, chronic obstructive pulmonary disease and cardiovascular disease, the nirmatrelvir/ritonavir prescription was associated with a decrease in 60-day hospitalization and death, with an adjusted risk ratio of 0.52 (95% confidence interval from 0.36 to 0.75).

CONCLUSIONS

Our data supports that nirmatrelvir/ritonavir prescription is associated with a risk reduction of 60-day COVID-19 related hospitalization and death, in outpatients with COVID-19.

The Link Between Sleep-Related Breathing Disorders and Idiopathic Pulmonary Fibrosis: Pathophysiological Mechanisms and Treatment Options-A Review

In recent years, several studies have examined the impact of sleep-disordered breathing (SBD) on the quality of life and prognosis of patients with idiopathic pulmonary fibrosis (IPF). Among these disorders, obstructive sleep apnea (OSA) and nocturnal hypoxemia (NH) are the most prevalent and extensively studied, whereas central sleep apnea (CSA) has only been documented in recent research. The mechanisms underlying the relationship between IPF and SBDs are complex and remain an area of active investigation. Despite growing recognition of SBDs in IPF, no standardized guidelines exist for their management and treatment, particularly in a population characterized by distinct structural pulmonary abnormalities. This review outlines the pathophysiological connections between sleep-breathing disorders (SBDs) and idiopathic pulmonary fibrosis (IPF), as well as current therapeutic options. A comprehensive literature search using PubMed identified relevant studies, confirming the efficacy of CPAP in treating severe OSA and CSA. While high-flow oxygen therapy has not been validated in this patient cohort, it may offer a potential solution for select patients, particularly the elderly and those with low compliance. Conventional oxygen therapy, however, is limited to cases of isolated nocturnal hypoxemia or mild central sleep apnea.

Exosomes as Therapeutic and Diagnostic Tools: Advances, Challenges, and Future Directions

Exosomes are tiny extracellular vesicles that are essential for intercellular communication and have shown great promise in the detection and treatment of disease. They are especially useful in the treatment of cancer, cardiovascular conditions, and neurological diseases because of their capacity to transport bioactive substances including proteins, lipids, and nucleic acids. Because of their low immunogenicity, ability to traverse biological barriers, and biocompatibility, exosome-based medicines have benefits over conventional treatments. Large-scale production, standardization of separation methods, possible immunological reactions, and worries about unforeseen biological effects are some of the obstacles that still need to be overcome. Furthermore, there are major barriers to the clinical use of exosomes due to their complex cargo sorting mechanisms and heterogeneity. Future studies should concentrate on enhancing separation and purification procedures, optimizing exosome engineering techniques, and creating plans to reduce immune system modifications. This review examines the most recent developments in exosome-based diagnostics and treatments, identifies current issues, and suggests ways to improve their clinical translation in the future.

Dynamic functional assessment of T cells reveals an early suppression correlating with adverse outcome in polytraumatized patients

Introduction

Most trauma patients require intensive care treatment and are susceptible to developing persistent inflammation and immunosuppression, potentially leading to multi organ dysfunction syndrome (MODS) and dependence on long term care facilities. T cells undergo changes in numbers and function post trauma. T cell dysfunction in polytraumatized patients was characterized using functional immunomonitoring to predict individual clinical outcome. Moreover, the potential to reverse T cell dysfunction using Interleukin (IL)-7 was examined.

Methods

Blood samples were drawn from healthy individuals and prospectively enrolled polytrauma patients (Injury Severity Score ≥ 18) on admission, 8, 24 and 48 hours, 5 and 10 days after. CD3/28-stimulated cytokine production of T cells in whole blood was assessed via Enzyme Linked Immuno Spot (ELISpot). T cell subsets were quantified via counting and flow cytometry. Unfavorable physical performative outcome was defined as death or new functional disability necessitating long term care. Secondary outcomes were the development of MODS and in-hospital mortality. IL-7 was added ex vivo to test reversibility of cytokine disturbances.

Results

34 patients were enrolled. The different outcome groups showed no difference in injury severity. Patients with favorable physical performative outcome revealed higher functional T cell specific Interferon γ (IFN-γ) and IL-17 (8 hours) and lower IL-10 production (day 5) and higher CD8 T cell concentrations. Patients without MODS development showed a higher IFN-γ (day 10), higher IL-2 (8 hours) and higher IL-17 production (admission, day 5). There were no differences regarding in-hospital mortality. Systemic blood IFN-γ, IL-2 and IL-10 concentrations only correlated with MODS (24 hours). Systemic CD8 T cell numbers correlated with functional IFN-γ production. Whole blood stimulation with IL-7 increased functional T cell IFN-γ release.

Discussion

Our study reveals an early characteristic overall T cell dysfunction of pro-inflammatory (IFN-γ, IL-2, IL-17) and immunosuppressive (IL-10) subtypes in polytraumatized patients. Our data indicates that rather the functional capacity of T cells to release cytokines, but not systemic cytokine concentrations can be used to predict outcome post trauma. We assume that the early stimulation of pro- and anti-inflammatory T cells benefits polytraumatized patients. Potentiation of functional IFN-γ release might be achieved by IL-7 administration.

Explainable SHAP-XGBoost models for pressure injuries among patients requiring with mechanical ventilation in intensive care unit

pressure injuries are significant concern for ICU patients on mechanical ventilation. Early prediction is crucial for enhancing patient outcomes and reducing healthcare costs. This study aims to develop a predictive model using machine learning techniques, specifically XGBoost combined with SHAP, to identify key risk factors of pressure ulcers in this population. Utilizing the MIMIC-IV 2.2 database, we included a cohort of 29,448 mechanically ventilated patients in ICU intensive unit. These patients were divided into a training set (20,614 patients, 70%) and an internal validation set (8,834 patients, 30%). Of these, 2,052 patients developed pressure injuries. We applied the XGBoost algorithm to build the predictive model and used SHAP analysis to identify the top ten factors influencing pressure ulcer development: 'sepsis', 'age', 'the count of platelet', 'length of ICU stay', 'PaO2/FiO2 ratio', 'hemoglobin concentration', 'admission type', 'renal disease', 'albumin concentration', and 'ethnicity'. The predictive model achieved an area under the ROC curve (AUC) of 0.797 (95% CI: 0.786-0.808) in the training set and 0.739 (95% CI: 0.721-0.758) in the validation set. Calibration curves demonstrated good fit, and the decision curve analysis indicated clinical utility. This study successfully developed a machine learning model that accurately predicts the risk of pressure ulcers in ICU patients with mechanical ventilation. This model could serve as a useful tool for guiding early interventions, ultimately reducing the incidence of pressure injuries in this vulnerable population. The integration of SHAP analysis offers insights into the most critical factors.

Time Variable Models of Severe Hemorrhagic Shock in Rats

BACKGROUND

Classical teaching dictates that damage control resuscitation is ideally implemented within the first or 'golden' hour after trauma-related hemorrhage. Given the heterogeneity of trauma, varied models must be utilized to guide ongoing investigation. We sought to determine exactly what happens during the 'golden hour' by varying hemorrhage and down times and mimicking venous or arterial bleeding while varying oxygen therapy, a readily available pre-hospital intervention, on survival in a small-animal rodent model.

METHODS

Rats were bled by 40% of their blood volume over 30 or 60 min, with varied 'down-times' of 30, 45, or 60 min. FiO2 was administered at 21% or 40%, mimicking nasal cannula. Multiple linear regression was performed between the independent variables and each measured outcome. Sub-group analyses were stratified by survival.

RESULTS

There was no statistically significant variation in end-organ insult (lactate), cardiac functioning (cardiac output or left ventricle fractional area of change), mean arterial pressure at end experiment, survival, or survival times among the groups.

CONCLUSIONS

This study adds to the data against an all-encompassing golden hour, as even a rapid hemorrhage with long down time did not decrease survival. Furthermore, we add to the body of literature in this field by examining cardiac markers of injury with transthoracic echocardiography.

Identification of a novel aminoglycoside nucleotidyltransferase gene in Morganella morganii from farm sewage

BACKGROUND

Aminoglycosides are important broad-spectrum antimicrobial agents. When combined with β-lactam drugs, these agents can be used to treat severe infections such as those causing sepsis. Identifying additional resistance mechanisms will guarantee the successful application of aminoglycoside agents in clinical practice.

METHODS

The isolate Morganella morganii A19 was obtained from a sewage sample from an animal farm by means of agar plate streaking. The agar dilution method was used to determine the minimum inhibitory concentrations (MICs) of the antimicrobial agents. Cloning of the predicted resistance gene was conducted, and its resistance function was assessed through MIC testing. The protein was expressed in E. coli, and the kinetic parameters were quantified. The analysis of novel resistance gene-related sequences, including their structures and evolutionary relationships, was performed using bioinformatic tools.

RESULTS

In Morganella morganii A19, a newly discovered chromosome-encoded aminoglycoside resistance gene named aadA37 was identified and characterized. The protein AadA37 exhibited the highest amino acid identity (57.14%) with the functionally characterized aminoglycoside adenylyltransferase AadA33. aadA37 confers resistance to spectinomycin, streptomycin and ribostamycin, and enzyme kinetic analysis also demonstrated that it had adenosine transfer activities against spectinomycin and streptomycin, with kcat/Km values of 0.66 × 103 M- 1 s- 1 and 1.63 × 103 M- 1 s- 1, respectively. The aadA37 gene and its homologs were not related to any mobile genetic element (MGE), and they were all found to be encoded on the chromosomes of the M. morganii strains.

CONCLUSION

A novel aminoglycoside resistance gene was identified from an environmental bacterium and characterized in this work. Identifying new resistance mechanisms will aid in the effective clinical use of antimicrobial agents for treating infectious diseases caused by pathogens harboring the same resistance genes.

SARS-CoV-2 vaccination reduces the risk of thrombotic complications in severe COVID-19

OBJECTIVES

The aim of this study was to evaluate the association between SARS-CoV-2 vaccination and the occurrence of thrombotic complications in patients admitted to intensive care for severe COVID-19 pneumonia.

DESIGN

Observational, descriptive, prospective, multicentre study.

SETTING

Intensive care units of five university hospitals.

PATIENTS

A total of 255 patients admitted to the intensive care unit (ICU) with SARS-CoV-2 pneumonia, confirmed by RT-PCR in throat swab or tracheal aspirate, starting the date the first vaccinated patient against SARS-CoV-2 was admitted in one of the participating ICUs, were included in the analysis.

MAIN VARIABLES OF INTEREST

Vaccination status against SARS-CoV-2 and thrombotic events.

RESULTS

18.8% of patients had received some form of vaccination. Thrombotic events occurred in 21.2% of patients. Lack of vaccination was associated with thrombotic events (OR 5.024; 95% CI: 1.104-23.123; p = 0.0037) and death (OR 5.161; 95% CI: 1.075-24.787; p = 0.04). ICU mortality was not associated with the occurrence of thrombotic complications.

CONCLUSIONS

In this series of patients, vaccination against SARS-CoV-2 reduced the risk of thrombotic events and mortality in patients with severe COVID-19 admitted to the ICU. Thrombotic complications did not alter ICU mortality.

Enhanced glomerular thrombosis in pronated animals with ARDS

BACKGROUND

Prone positioning is part of the management of acute respiratory distress syndrome (ARDS) and has been demonstrated to successfully improve the ventilation-perfusion match and reduce mortality in patients with severe respiratory failure. However, the effect of pronation on other organs than the lungs has not been widely studied. This study aimed to compare abdominal edema, perfusion and inflammation in supine and prone positioning in a porcine ARDS model.

METHODS

Seventeen piglets were randomized into two groups: a supine group (n = 9) and a prone group (n = 8). Both groups received endotoxemic infusion and were observed for 6 h. Three animals per group underwent positron emission tomography-magnetic resonance imaging (PET-MRI) for imaging acquisition. Hemodynamic and respiratory parameters were recorded throughout the protocol. Inflammation was assessed by measuring cytokine concentrations in blood, ascites and the abdominal organs' tissue. The edema in abdominal organs was assessed by wet-dry ratio and pathophysiological analysis of tissue samples and by MRI and PET measurements from volumes of interest (VOIs) delineated in abdominal organ in MRI and PET images. The abdominal organs' perfusion was also assessed by MRI and PET measurements.

RESULTS

The prone group had a faster CO2 washout and needed a lower positive end-expiratory pressure to maintain the desired oxygenation. In the prone group duodenal edema was lower (measured with wet-dry ratio) and renal perfusion, by both MRI and PET measurements, was lower than half compared to the supine group (MRI, perfusion fraction, f: supine group 0.13; prone group 0.03; p-value 0.002. PET Flow: supine group 1.7; prone group 0.4 ml/cm3/min; p-value 0.002). In addition, the histopathological samples of the kidneys showed a higher incidence and extent of glomerular thrombosis in the prone group.

CONCLUSIONS

In a porcine ARDS model, prone positioning was associated with enhanced glomerular thrombosis and low renal perfusion.

Anesthesia for bronchoscopy interventional therapy in a patient with Gorham-Stout disease, lung cancer, and right lung atelectasis: a case report

BACKGROUND

Gorham-Stout disease (GSD) is an extremely rare disease of unknown etiology, characterized by painless and progressive bone resorption that may affect multiple bones throughout the body. GSD primarily involves the maxillofacial region, leading to facial disfigurement and reduced joint stability, thereby increasing the risk of challenging tracheal intubation. Limited cases have been reported on the co-occurrence of GSD in the maxillofacial region with lung cancer and right lung atelectasis, particularly regarding anesthesia management for bronchoscopy interventional therapy in such patients.

CASE PRESENTATION

This report presents a successful case of a patient with maxillary GSD and right lung atelectasis secondary to lung cancer who underwent bronchoscopy interventional therapy under general anesthesia. The perioperative course was uneventful, with no complications observed.

CONCLUSION

Anesthesia management is critical in the surgical treatment of patients with GSD. Airway management poses unique challenges, necessitating thorough preoperative evaluation and implementation of strategies to address potential intubation difficulties. Additionally, vigilance for intraoperative complications is essential.

Clinical outcomes and peripheral tissue oxygen saturation monitoring of the knee region by near-infrared spectroscopy in circulatory shock: a prospective observational cohort study

BACKGROUND

In circulatory shock, tissue hypoperfusion leads to adverse outcomes. We hypothesized that peripheral tissue oxygen saturation (StO2), measured with near-infrared spectroscopy (NIRS), could provide a non-invasive method for assessing tissue hypoperfusion and predicting pending organ dysfunction and mortality.

METHODS

ASSESS-SHOCK was a prospective, observational study enrolling circulatory shock patients from April 2019 to May 2023 in three intensive care units (ICU). Adult patients fulfilling the criteria for circulatory shock within 24 h of ICU admission were eligible. Patients underwent continuous 48 h StO2 (INVOS™) monitoring of the knee region. To express the burden of tissue hypoperfusion we calculated mean StO2 and areas below predefined StO2 thresholds. The primary outcome, change in Sequential Organ Failure Assessment (SOFA) score, was dichotomized to improvement or non-improvement in SOFA score from enrollment to day 7 or ICU discharge. Death within 7 days was considered as SOFA non-improvement. 90-day mortality was among the secondary outcomes.

RESULTS

We included 256 patients. Due to several reasons, including the COVID-19 pandemic, the patient sample was not consecutive. The median of 48-h mean StO2 was 68.3% (interquartile range [IQR] 57.5-74.1) in SOFA-improvers (n = 171), compared to 63.5% (IQR 52.7-70.8, p = 0.020) in non-improvers (n = 85), and 68.7% (IQR 58.2-74.5) in 90-day survivors, versus 60.9% (IQR 49.5-67.1, p < 0.001) in non-survivors. There were no statistically significant differences in the areas below predefined StO2 thresholds between the SOFA-improvers and non-improvers but all the areas were larger in 90-day non-survivors. The 90-day mortality was 27.0% (n = 69). In multivariable analyses 48-h mean StO2 was associated with 90-day mortality (Odds ratio [OR] 0.97, 95% confidence interval [CI 95%] 0.94-1.00, p = 0.047) but not with SOFA change. The association with mortality was, however, no longer significant in multivariable analyses after exclusion of the last 6 hours of StO2 registration in the patients (n = 29) who died during the 48 h registration (OR 0.97, CI 95% 0.94-1.00, p = 0.062).

CONCLUSIONS

Lower peripheral StO2 was associated with 90-day mortality in critically ill patients with circulatory shock but not with persisting or worsening organ dysfunction. NIRS shows promise as a non-invasive monitor of tissue perfusion in circulatory shock.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03814564, registered 15 January 2019.

A Case of Severe Community-Acquired Pneumonia Caused by Coinfection of Five Pathogens

Introduction

Severe pneumonia is a serious pulmonary infection, and its high morbidity and mortality are associated with underlying diseases, treatment-induced immunodeficiency, co-infection of multiple pathogens, and increase of multi-resistant pathogens; For severe community-acquired pneumonia (SCAP) in immunocompromised patients, most of which are infected with rare atypical pathogens, mNGS as an unbiased and hypothesis-free approach to rapidly detect potential infectious agents in pulmonary mixed infections. The cases of simultaneous co-infection of five non-respiratory core pathogens represented by Nocardia farcinica have not been reported.

Case Presentation

This article will elaborate on a case of immunocompromised patient with nephrotic syndrome after corticosteroid treatment, who was diagnosed as SCAP after hospital admission and relevant laboratory examination. Bronchoalveolar lavage fluid (BALF) metagenome next-generation sequencing (mNGS) method identified as Nocardia farcinica, Aspergillus fumigatus, Pneumocystis jirovecii, cytomegalovirus and human coronavirus OC43 five pathogens co-infection, the patient improved and he was discharged after receiving the combination treatment of imipenem, ganciclovir, compound sulfamethoxazole, and fluconazole.

Conclusion

For SCAP patients with immunocompromised, there may be possible co-infection of multiple rare pathogens, low positive rate of conventional laboratory tests, mNGS can quickly and accurately identify pathogens, which can be used for targeted drug treatment, promote the early recovery of patients and reduce the abuse of broad-spectrum antibiotics.

Effects of in-bed cycling in critically ill adults: A systematic review and meta-analysis of randomised clinical trials

BACKGROUND

Impairments in intensive care unit (ICU) survivors can last up to 5 years post-discharge. Finding effective treatments to palliate and prevent them is essential, and in-bed cycling is a way to palliate the effects of prolonged immobilisation.

OBJECTIVE

To evaluate the effects of in-bed cycling in critically ill adults regarding recovery status, mortality, physical performance and quality of life.

METHODS

We followed PRISMA 2020 guidelines. The search was conducted in Cinahl, Medline, Scopus and Web of Science from their inception to October 2024. We included randomised clinical trials with critically ill adults who performed in-bed cycling alone or with another treatment while in ICU, compared to no intervention, placebo, rehabilitation or standard care, assessing recovery status, mortality, physical performance or quality of life. Methodological quality and risk of bias were evaluated. A meta-analysis was performed.

RESULTS

Thirty-two studies were included in the review, and 22 studies in the meta-analysis. A total of 3,052 participants (≥18 years old) admitted to different types of ICUs were included. Results showed significant differences regarding ICU length of stay (n = 1,564; MD -0.93; 95 % CI -1.64 to -0.21; P = 0.01) and hospital length of stay (n = 1,189; MD -1.78; 95 % CI -3.16 to -0.41; P = 0.01), mechanical ventilation duration (n = 1,024; MD -0.51; 95 % CI -0.92 to -0.11; P = 0.01) and functional status (n = 400; MD 44.88; 95 % CI 3.11-86.65; P = 0.04) favouring in-bed cycling plus rehabilitation compared to rehabilitation. However, no significant differences were found regarding mortality, muscle strength, ICU-acquired weakness or quality of life. Different programme duration did not significantly affect hospital length of stay.

CONCLUSION

In-bed cycling plus rehabilitation significantly reduced ICU and hospital length of stay, mechanical ventilation duration and improved functional status compared to rehabilitation. Further research is needed to analyse long-term effects and standardise interventions.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42022309311; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022309311.

Short- and long-term mortality in critically ill patients with solid cancer. The Vall d'Hebron Intensive Care Unit-Vall d'Hebron Institute of Oncology Cohort: a retrospective study

OBJECTIVE

To describe in-hospital and one-year mortality and to identify prognostic variables associated with mortality.

DESIGN

Retrospective cohort study.

SETTING

Tertiary referral hospital in Barcelona (Spain).

PATIENTS

Consecutive patients with solid cancer and unplanned admission to the ICU over a ten year period (2010-2019).

MAIN VARIABLES OF INTEREST

In-hospital mortality, one-year mortality, type of cancer, metastatic disease, ECOG, APACHE, SOFA, invasive mechanical ventilation, vasoactive drugs, renal replacement therapy.

RESULTS

Three hundred and ninety-five patients were admitted to the ICU; 193 (48.8%) had metastatic disease, and 22 (5.9%) presented neutropenia. The median SOFA score on day 1 of ICU admission was 6 (3-9). ICU, in-hospital, and one-year mortality were 27.9% (110 patients), 39% (139 patients), and 61.1% (236 patients), respectively. A non-surgical admission, a higher ECOG, a SOFA score > 9 on day 1, a non-decreasing SOFA score on day 5, and requiring invasive mechanical ventilation were factors associated with in-hospital mortality. ECOG, inability to resume anticancer therapy, and ICU admission due to respiratory failure were associated with one-year mortality in hospital survivors.

CONCLUSION

Survival in critically ill solid cancer patients is substantial, even when metastatic disease exists. Short-term outcomes were associated with ECOG and organ dysfunction, not cancer per se. The prognosis of patients with a non-decreasing SOFA score on day 5 is poor, especially when the SOFA score on day 1 was >9. Long-term mortality was associated with functional status and inability to resume anticancer therapy.

Decannulation ahead: a comprehensive diagnostic and therapeutic framework for tracheotomized neurological patients

BACKGROUND

Decannulation in tracheotomized neurological patients is often complicated by severe dysphagia, which compromises airway safety and delays weaning. Additional challenges, including reduced cough strength, excessive bronchial secretions, and altered airway anatomy exacerbate weaning issues, thereby increasing morbidity and mortality. This review summarizes diagnostic procedures and therapeutic options crucial for the rehabilitation of tracheotomized patients.

MAIN BODY

Key diagnostic strategies for assessing decannulation readiness focus on airway protection, airway patency, bronchial secretion management, and cough function. These are collectively introduced as the A2BC criteria in this review. Advanced tools such as flexible endoscopic evaluation of swallowing, endoscopic assessment of airway anatomy, measurement of cough strength, and intrathoracic pressure are essential components of a systematic evaluation. Therapeutic interventions encompass restoring physiological airflow, behavioral swallowing treatment, secretion management, and pharyngeal electrical stimulation. The proposed decannulation algorithm integrates two pathways: the "fast-track" pathway, which facilitates rapid decannulation based on relevant predictors of decannulation-success, and the "standard-track" pathway, which progressively increases cuff deflation intervals to build tolerance over time.

CONCLUSION

Successful decannulation in neurological patients demands a multidisciplinary, patient-centered approach that combines advanced diagnostics, targeted therapies, and structured management pathways. The proposed algorithm integrates fast-track and standard-track pathways, balancing rapid diagnostics with gradual weaning strategies. This framework promotes flexibility, enabling clinicians to tailor interventions to individual patient needs while maintaining safety and optimizing outcomes.

The mediating role of perceived overqualification in the relationship between emotional labor and mindfulness among nurses in China

Background

Perceived overqualification has attracted considerable attention from labor economists and managers, who perceive it as a risk factor affecting workforce stability. Mindfulness is closely associated with emotional labor, however, the potentiatl mechanisms underlying the relationship between mindfulness and emotional labor remain ambiguous. This study seeks to investigate the mediating role of perceived overqualification in the relationship between emotional labor and mindfulness among clinical nurses.

Methods

A total of 354 clinical nurses were assessed using the Mindful Attention Awareness Scale, the Perceived Overqualification Scale, and the Emotional Labor Scale. The SPSS version 27.0 statistical analysis software was employed for the basic organization and analysis of the survey data. A structural equation model was used to assess the mediating role of perceived overqualification between mindfulness and the emotional labor of clinical nurses.

Results

The study indicated that the level of mindfulness and emotional labor among clinical nurses was moderate to high, whereas perceived overqualification was moderate. A significant negative correlation was observed between perceived overqualification and mindfulness (r = -0.270, P < 0.001). In contrast, mindfulness was significantly positive correlated with deep acting (r = 0.110, P < 0.05) and significantly negatively correlated with surface acting and emotional expression requirements (r = -0.294, r = -0.278, P < 0.001). Furthermore, perceived overqualification acted as a mediator between mindfulness and surface acting as well as between mindfulness and emotional expression requirements, with mediating effect sizes of 20% and 12.5%, respectively.

Conclusion and recommendation

By promoting mindfulness among clinical nurses while reducing their perceived overqualification may enhance their emotional labor capabilities, thereby fostering positive outcomes for their physical and mental health, and contributing to the advancement of high-quality nursing services.

Return to work after major trauma: a systematic review

INTRODUCTION

Individuals suffering from major trauma and survive, often face diverse physical, psychological, and cognitive restrictions which can influence the (health-related) quality of life and the ability to work. Even though, return to work is not necessarily related to the health status of the individual, but it is viewed as a sign of successful reintegration and is a vital parameter of recovery.

OBJECTIVE

The aim was to systematically review factors influencing return to work (RTW) after suffering from major trauma.

MATERIAL AND METHODS

A search on seven databases was performed. The identified publications were selected according to the inclusion criteria: adults (≥ 16 years) who suffered a major trauma (Injury Severity Score ≥ 16) in studies that explored factors associated with RTW. Risk of bias was assessed with the 'Quality in Prognostic studies' tool. Due to reporting quality of the included studies no meta-analysis was performed. Data were clustered, qualitatively analyzed and factors are assessed based on the strength of evidence. (PROSPERO registration: CRD42022357649).

RESULTS

12 studies with 6907 participants (mean age 45 years, 75% males, mean ISS 28) were included. The included studies had low to moderate risk of bias for most domains, the domain 'study confounding' had most often a high risk of bias. Many factors were identified including physical (e.g., injury locations), personal (e.g., age) but also environmental factors (e.g., preinjury income). Only four factors (age, educational level, intensive care unit (ICU) stay and Length of stay (LOS) hospital) are based on moderate or strong evidence. The identified factors reflect the complex interactions within the process of regaining the ability to work after major trauma.

DISCUSSION

This systematic review was able to map the evidence surrounding factors affecting RTW after major trauma. Most of the identified factors are currently only based on limited evidence. According to these factors, younger patients with a higher educational level who have a shorter LOS in hospital and a shorter ICU stay might have better chances of RTW.

Mortality time frame variability in septic shock clinical trials: A systematic review

OBJECTIVE

We sought to delineate the mortality outcome time frames reported in septic shock randomized control trials (RCTs).

DESIGN

Systematic review of PubMed, EMBASE, and the Cochrane Database of Systematic Reviews.

SETTING

Intensive care units.

PARTICIPANTS

Studies that included adult patients with septic shock.

INTERVENTIONS

Any type of intervention.

MAIN VARIABLES OF INTEREST

Information about the study, specific patient population, type of study intervention, specific intervention, and number of patients. Mortality time frames were analyzed for geographical differences and changes over time.

RESULTS

The search yielded 2660 unique citations. After screening, 132 eligible studies were identified. A total of 234 mortality time frames were collected from the included studies, of which 15 timeframes were unique. The most frequently reported time frame was 28-day mortality (n = 98, 74% of trials), followed by hospital mortality (n = 35, 27%), ICU mortality (n = 30, 23%), and 90-day mortality (n = 29, 22%). The most reported mortality time frame was 28 days in studies from every continent except Africa. The studies published between 2008 and 2013 (25%) more frequently reported hospital and ICU mortality combination than studies published between 2014 and 2019 (11.4%) (P = 0.043).

CONCLUSIONS

There was considerable variability in the mortality time frames reported in ICU-based septic shock trials. This variability may lead to under or overestimation of the problem, overlooking the effectiveness of the interventions studied, and further limiting the application of trials and their pooling in meta-analyses. A consensus regarding time frame reporting in septic shock trials is long overdue.

Gut Microbiome dysbiosis and immune activation correlate with somatic and neuropsychiatric symptoms in COVID-19 patients

BACKGROUND

Infection with SARS-CoV-2, the virus responsible for COVID-19, can lead to a range of physical symptoms and mental health challenges, including stress, anxiety, and depression. These effects are particularly pronounced in hospitalized patients, likely due to the virus's direct and indirect impact on the nervous system. Gut dysbiosis, an imbalance in the gut microbiome, has been implicated in immune dysfunction and chronic inflammation in COVID-19 patients. However, the interactions between gut microbiome composition and the physical and mental symptoms of COVID-19 remain incompletely understood.

METHODS

We investigated the association between physical and mental symptoms, cytokine profiles, and gut microbiota composition in 124 hospitalized COVID-19 patients. We collected data on demographics, COVID-19 severity, and mental health indicators (stress, anxiety, and depression). Gut microbiome profiling was performed using full-length 16 S rRNA gene sequencing to evaluate microbial diversity and composition.

RESULTS

COVID-19 severity was categorized as low (27.4%), moderate (29.8%), or critical (42.8%). Common symptoms included fever (66.1%) and cough (55.6%), while somatic symptoms (27.3%), anxiety (27.3%), depressive symptoms (39%), and stress (80.5%) were frequently self-reported. Elevated interleukin-6 levels in severe cases highlighted systemic inflammation, reduced gut bacterial diversity, particularly among women and obese patients, correlated with higher disease severity. Notably, the genus Mitsuokella was associated with increased physical symptoms and mental distress, while Granulicatella was linked to critical illness.

CONCLUSIONS

Our findings reveal significant associations between mental health status, systemic inflammation, and gut dysbiosis in hospitalized COVID-19 patients. These results indicate the potential for microbiome-targeted therapies to mitigate psychological and physical complications and improve recovery outcomes in this population.

Heated high flow nasal cannula and bilevel positive airway pressure in pediatric asthma exacerbations

OBJECTIVE

Heated High Flow Nasal Cannula (HHFNC) and Bilevel Positive Airway Pressure (BPAP) are noninvasive respiratory support modalities used in pediatric asthma exacerbations. We aim to examine differences in characteristics and outcomes for patients admitted to the Pediatric Intensive Care Unit (PICU) on standard therapy (ST) alone (continuous albuterol and systemic corticosteroids), ST plus HHFNC, and ST plus BPAP.

METHODS

This is a retrospective and prospective observational cohort study. Chi-Squared/Fisher's exact and Kruskal Wallis tests were used for categorical and continuous outcomes, respectively.

RESULTS

129 patients were included. Younger patients were placed on HHFNC while more severe patients were placed on BPAP. A multiple linear regression controlling for age, sex, race, ethnicity, and exacerbation severity revealed that patients admitted on BPAP had a longer duration of continuous albuterol compared to patients on ST alone (p = 0.02). No differences were found in respiratory support escalation, duration of respiratory support, or adverse events. The BPAP group had the most sedation use and longest length of stay (LOS). Median hourly respiratory rates (RR) increased in the HHFNC group over the first 12 h of admission and remained stable or decreased in the ST and BPAP groups.

CONCLUSIONS

This study found that BPAP use in pediatric asthma exacerbations is associated with increased exacerbation severity, longer duration of continuous albuterol, increased sedation use, and longer LOS. Although a multiple linear regression analysis was performed to control for multiple covariates including exacerbation severity, it is possible that intrinsic patient characteristics influenced these outcomes rather than BPAP usage.

Implementation of Simulation-Based Technology to Promote Safety in the Nursing Handover in the Intensive Care Unit

AIMS AND OBJECTIVES

To evaluate the impact of implementing a prototype of simulation-based educational technology on raising awareness among ICU nurses, improving communication in nursing handover, and promoting patient safety.

DESIGN

Qualitative study based on the conceptual framework of patient safety. The COREQ tool guided the presentation of the research report.

METHODS

The research was conducted with 18 nurses from the ICU of a public hospital in Rio de Janeiro, Brazil, who worked directly in nursing handover. The technology implemented was developed based on communication failures identified in a previous stage of the macro research project. This evidence supported the development of a simulated scenario of a nursing handover of a critical patient, which was recorded in audio and video. The video addressed content (absence, incompleteness and lack of ordering of information) and behavioural errors (interruptions, distractions, noise and lack of clarity) during communication between intensive care nurses. The video was implemented with nurses through the use of telesimulation with debriefing. Finally, the nurses were subjected to a semi-structured interview to evaluate the potential of the technology, whose data underwent thematic analysis with an inductive model.

RESULTS

The nurses recognised the communication failures portrayed as part of their daily practice, reflected on their mistakes, and on actions to be adopted to change behaviour during the handover.

CONCLUSIONS

The simulation-based technology prototype has the potential to promote self-reflection and raise nurses' awareness of the need to change behaviours during the handover.

RELEVANCE TO CLINICAL PRACTICE

The simulation-based technology prototype can be applied as an educational strategy to improve communication safety in nursing handover.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Antimicrobial strategies of lower respiratory tract infections in immunocompromised patients based on metagenomic next-generation sequencing: a retrospective study

BACKGROUND

Immunocompromised patients with Lower Respiratory Tract Infections (LRTI) frequently encounter a diverse range of pathogenic infections, characterized by rapid disease progression and significant mortality rates due to reckless or excessive utilization of antibiotics. Therefore, it is crucial to promptly and accurately identify the causative microorganisms for pathogen diagnosis and clinical decision-making. The objective of this study is to evaluate the clinical applicability of metagenomic next-generation sequencing (mNGS) in the diagnosis and management of LRTI, as well as its impact on empirical antibacterial therapy for patients with varying immune statuses.

METHODS

We conducted a comparative analysis of positivity rate, detection accuracy, pathogen spectrum, duration of treatment (DOT), and antibiotic management in a cohort of 283 patients diagnosed with lower respiratory tract infections.

RESULTS

The positive detection rate was higher in mNGS compared to conventional culture in both immunocompetent group (89.92% vs. 28.57%, P < 0.001) and immunocompromised group (84.44% vs. 33.33%, P < 0.001). The antibiotic escalation in the immunocompromised group was more frequent than that in the immunocompetent group (49.00% vs. 31.00%, P = 0.018), but no difference was observed for antibiotic de-escalation (20.00% vs. 15.00%, P = 0.458).

CONCLUSIONS

The application of mNGS can significantly enhance the pathogen detection rate and optimize antimicrobial drug management in immunocompromised patients with LRTI.

Video Versus Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults: A Systematic Review and Meta-Analysis

Background/Objectives: Endotracheal intubation in critically ill patients presents significant challenges due to anatomical and physiological complexities, making airway management crucial. Video laryngoscopy (VL) has emerged as a promising alternative to direct laryngoscopy (DL), offering improved and higher success rates. This systematic review and meta-analysis evaluated the comparative efficacy and safety of VL versus DL in critically ill adults. Methods: A systematic search was conducted in PubMed, Embase, and Cochrane Library through August 2024 following PRISMA-2020 guidelines. Randomized controlled trials comparing VL and DL in critically ill adult patients were included. The RoB 2.0 tool assessed bias, and GRADE evaluated the certainty of evidence. The primary outcome was first-attempt success; secondary outcomes included intubation time, glottic visualization, and complications. Random effects models were used for data synthesis. Results: Fifteen studies (4582 intubations) were included. VL improved first-attempt success rates (RR 1.12; 95% CI: 1.04-1.21; I2 = 87%). It also reduced esophageal intubation (RR 0.44; 95% CI: 0.26-0.75), dental injuries (RR 0.32; 95% CI: 0.16-0.67), and poor glottic visualization. No significant differences were found in hypoxemia, hypotension, or mortality. Conclusions: VL enhances intubation success and reduces specific complications, particularly in difficult airways. However, high heterogeneity and low certainty of evidence warrant further studies to clarify its impact on critical patient outcomes.

IL-6 Baseline Values and Dynamic Changes in Predicting Sepsis Mortality: A Systematic Review and Meta-Analysis

Sepsis, a life-threatening condition arising from a dysregulated immune response to infection, is a significant health burden globally. Interleukin-6 (IL-6), an inflammatory cytokine produced by immune cells as a response to infection and tissue damage, plays a key role in the pathogenesis of sepsis. This systematic review and meta-analysis aimed to investigate the association of the baseline plasma levels of IL-6, and the dynamic change in these levels over a timespan of 96 h, with short-term mortality. A systematic literature search was conducted across multiple databases. Studies were included if they assessed the independent prognostic value of IL-6 in adult sepsis patients, used well-defined sepsis criteria, and reported at least one IL-6 measurement. Pooled effect estimates for the association between IL-6 and 28-30-day mortality were determined using logistic regression and AUROC analysis. Thirty-one studies, encompassing 4566 patients, were included. While baseline IL-6 levels and 96 h IL-6 clearance were not significantly associated with mortality risk (pooled OR 1.001, 95% CI 0.999-1.003 and 1.019, 95% CI 0.925-1.112, respectively), AUROC analysis indicated moderate-to-good discriminatory power for both baseline (0.701, 95% CI 0.660-0.742) and 96 h IL-6 clearance (0.828, 95% CI 0.736-0.919) in predicting 28-day mortality. While not a strong independent predictor, IL-6 demonstrates some discriminatory ability, suggesting its potential value in conjunction with other biomarkers.

Triggers, Types, and Treatments for Kounis Syndrome: A Systematic Review

Background: Kounis syndrome (KS), also known as allergic myocardial infarction, presents in three variants. This condition is often underrecognized due to limited knowledge and its variable presentation. To address these limitations, the present review aims to describe the triggers, types, management, and patient outcomes of KS. Methods: In this systematic review, PubMed and Scopus were used to identify publications of clinical case reports; variables included sociodemographic characteristics, clinical manifestations, triggers, treatments, and outcomes. Data from the articles´ abstracts were assessed by two corresponding authors, and subsequently, each case was analyzed by two coauthors, validated and analyzed with Stata 12. To categorize each Kounis type, mean and proportion comparison tests were performed, and measures of association were obtained using logistic regression and expressed as odds ratios. Results: A global distribution was identified, with predominance in the Northern Hemisphere. Type I KS was the most reported variant, and most of the patients were adult men. Most of the patients presented variability in the treatment and outcomes. Conclusions: KS may represent a diagnostic challenge, and underdiagnosis could explain the lack of uniformity in the diagnostic and assessment process. Our results highlight a need for improved approaches based on patient history for correct diagnosis and preventing recurring events.

Comparison of the Predictive Capacity of Oxygenation Parameters, Oxygenation Indices, and CURB-65 to Mortality, Mechanical Ventilation, and Vasopressor Support in Community-Acquired Pneumonia at Different Altitudes

Background: Populations residing at high altitudes display distinct physiological adaptations that are essential for understanding respiratory diseases. However, there is limited research on how these adaptations affect the assessment and prognosis of community-acquired pneumonia (CAP). Methods: A prognostic validation nested within a retrospective cohort was conducted on subjects with pneumonia admitted to two high-complexity institutions in Colombia at different altitudes above sea level. The receiver operating characteristic (ROC) curves were calculated for SaO2, PaO2, SpO2, A-a O2 gradient, a-A index, PaO2/FiO2, SpO2/FiO2, and the CURB-65 score to predict 30-day mortality, requirement for invasive mechanical ventilation (IMV), and need for vasopressor support. Results: 3467 were selected for analysis, with 73.7% (2557/3467) residing at high altitudes and 26.2% (910/3467) at low altitudes. The CURB-65 score  ≥ 2 showed a performance in predicting mortality of 0.707 (95% CI: 0.653-0.761; p < 0.001) at low altitudes and 0.737 (95% CI: 0.709-0.765; p < 0.001) at high altitudes. The PaO2/FiO2 ≤ 300 showed a performance in predicting the need for IMV and vasopressor support of 0.734 (95% CI: 0.685-0.783; p < 0.001) and 0.724 (0.674-0.775; p < 0.001) at high altitudes, respectively. The SpO2/FiO2 ≤ 350 showed a performance in predicting the need for IMV of 0.679 (0.507-0.85; p < 0.001) at low altitudes. The A-a O2 gradient ≥ 10 showed a performance in predicting the need for vasopressor support of 0.686 (95% CI: 0.537-0.835; p=0.06) at low altitudes. Conclusion: In patients with CAP at altitudes above 2500 m above sea level, PaO2/FiO2, SpO2/FiO2, and the A-a O2 gradient show a greater predictive capacity for 30-day mortality, need for IMV, and vasopressor requirements. The CURB-65 score showed a good predictive performance.

Application Results of an Extracorporeal Therapy Protocol in Cardiorespiratory Arrest: A Historical Cohort Study

Background/Objectives: This study sought to evaluate the clinical profile, in-hospital management, prognosis, and survival of patients treated for cardiac arrest using extracorporeal therapy in a third-level Spanish hospital before and after the therapy was protocolised. Methods: This study is a historical single-centre cohort study that was conducted from January 2009 to February 2024. In 2019, an in-hospital extracorporeal reanimation therapy protocol was established in the centre's Coronary Intensive Care Unit. As a result, the cohort was split into two groups: the Pre-Protocol group (between 2009 and December 2018) and the Post-Protocol group (between 2019 and February 2024). Results: A total of 26 patients were recruited, i.e., 10 in the first cohort and 16 in the second, with acute myocardial infarction being the most prevalent cause in both cohorts. A 30% (3) to 43.65% (7) increase in survival was observed between the two cohorts (p = 0.48), with CPC 1-2 neurological functionality exceeding 85% of cases in both cohorts (p = 0.7). The mean time from cardiac arrest to the application of extracorporeal therapy decreased from 104.1 min to 41.87 min (p = 0.09). The longer duration of ECMO (p = 0.03) and the longer hospital stay (p = 0.002) are due to a higher survival. Conclusions: The results show a trend in improvement outcomes. The small cohort size makes it difficult to draw robust conclusions, but we want to highlight the importance of applying a specific protocol based on standardised patient selection criteria and the establishment of extracorporeal reanimation therapy.

Sedation management and processed EEG-based solutions during venovenous extracorporeal membrane oxygenation: a narrative review of key challenges and potential benefits

Extracorporeal membrane oxygenation (ECMO) is an established technique for managing severe cardiorespiratory failure. However, it is invasive and requires profound analgo-sedation during initiation and often throughout the therapy. Managing sedation in venovenous (VV) ECMO patients is particularly challenging due to the impact of ECMO circuits on pharmacokinetics and specific patient requirements. This can lead to unpredictable sedative effects and require multiple drugs at higher doses. Additionally, sedation is usually managed with traditional scoring methods, which are subjective and invalid during neuromuscular blockade. These uncertainties may impact outcomes. Recent clinical practice increasingly focuses on reducing sedation to enable earlier physiotherapy and mobilisation, particularly in patients awaiting transplants or receiving mechanical circulatory support. In this context, processed electroencephalogram-based (pEEG) sedation monitoring might be promising, having shown benefits in general anaesthesia and intensive care. However, the technology has limitations, and its benefits in ECMO practice have yet to be formally evaluated. This review provides insights into the challenges of ECMO sedation, including pharmacokinetics, unique ECMO requirements, and the implications of inadequate sedation scores. Finally, it includes a brief overview of the practicality and limitations of pEEG monitoring during VV-ECMO, highlighting a significant research gap.

Associations between sepsis occurrence, hemoglobin level and mortality in patients with non-trauma hemorrhagic brain injuries: trajectory-based analysis

BACKGROUND

The impact of concurrent sepsis on the prognosis in patients with non-traumatic hemorrhagic brain injury (HBI) remains unclear, and the appropriate hemoglobin (HGB) level in HBI patients with sepsis has not been investigated. This study aimed to investigate the impact of sepsis in HBI and the prognosis of patients with different HGB trajectories with/without sepsis.

METHODS

The association between sepsis and prognosis (including neurologic outcome and 28-day mortality) in patients with non-trauma HBI was investigated, and multivariate logistic model, propensity score matching (PSM), and inverse-probability-weighted regression adjustment (IPWRA) were used to reach a causal relationship. Group-based trajectory analysis was adopted to explore the associations between HGB trajectories and outcomes.

RESULTS

A total of 3,040 patients were included. Compared with the HBI-without-sepsis group, the HBI-with-sepsis group had higher 28-day mortality and worse neurological outcomes. After adjusting for confounders, the association between sepsis and mortality remains significant in multivariate logistic model (OR 2.31, 95%CI 1.77-3.01), PSM analysis (212/942 vs. 130/942, p < 0.001) and IPWRA model (ATE 0.073, 95%CI 0.04-0.09). Based on 72-h HGB data, four HGB-trajectories were identified. In HBI-without-sepsis cohort, OR for mortality decreased from HGB-traj2 (OR: 0.56, 95% CI 0.33-0.96) to HGB-traj4 (0.26, 95% CI 0.11-0.59), referred to HGB-traj1. But this decreasing trend became non-significant in HBI-with-sepsis cohort. Sensitivity analyses showed similar results.

CONCLUSION

In HBI, concurrent sepsis was associated with higher mortality rate. Furthermore, there was an inverse gradient relationship between HGB level and mortality in HBI patients without sepsis, while this association became non-significant in those with sepsis.

Thromboembolic Events in the Era of COVID-19: A Detailed Narrative Review

COVID-19, caused by the SARS-CoV-2 virus, is not only characterized by respiratory symptoms but is also associated with a wide range of systemic complications, including significant hematologic abnormalities. This is a comprehensive review of the current literature, using PubMed and Google Scholar, on the pathophysiology and incidence of thromboembolic events in COVID-19 patients and thromboprophylaxis. COVID-19 infection induces a prothrombotic state in patients through the dysregulation of the renin-angiotensin-aldosterone system (RAAS), endothelial dysfunction, elevated von Willebrand factor (vWF), and a dysregulated immune response involving the complement system and neutrophil extracellular traps (NETs). As a result, thromboembolic complications have emerged in COVID-19 cases, occurring more frequently in severe cases and hospitalized patients. These thrombotic events affect both venous and arterial circulation, with increased incidences of deep venous thrombosis (DVT), pulmonary embolism (PE), systemic arterial thrombosis, and myocardial infarction (MI). While DVT and PE are more common, the literature highlights the potential lethal consequences of arterial thromboembolism (ATE). This review also briefly examines the ongoing discussions regarding the use of anticoagulants for the prevention of thrombotic events in COVID-19 patients. While theoretically promising, current studies have yielded varied outcomes: Some suggest potential benefits, whereas others report an increased risk of bleeding events among hospitalized patients. Therefore, further large-scale studies are needed to assess the efficacy and safety of anticoagulants for thromboprophylaxis in COVID-19 patients.

Prospective cohort study on characteristics, associated factors and short-term prognosis of sleep and circadian rhythm in intensive care unit: protocol for the SYNC study

INTRODUCTION

Acute sleep and circadian rhythm (SCR) disruption can lead to a range of negative physical and mental consequences, such as depression, delirium, respiratory dysfunction and increased mortality. In the intensive care unit (ICU), the unique environment can exacerbate disruptions in SCR. Few studies have identified the characteristics of SCR in the ICU, and the roles of patient characteristics, illness and medical interventions in ICU SCR remain unclear. A single-centre prospective cohort study, called SYNC study (Sleep and circadian rhYthm in iNtensive Care unit), will be conducted to explore the characteristics and associated factors of SCR and investigate the short-term prognosis among patients in the surgical ICU.

METHODS AND ANALYSIS

Patients from a surgical ICU at a tertiary teaching hospital will be enrolled. SCR will be assessed by both objective and subjective indicators, including melatonin secretion rhythm, activity rhythm, sleep pattern and perceived sleep quality. Data on eight potential factors that influence SCR, including light exposure, noise level, pain level, nighttime disturbances, mechanical ventilation, sedative and analgesic use, meal pattern and restraints, will be collected. These data will be gathered in the first 3 days after ICU admission. Short-term prognostic indicators, including anxiety, depression, cognitive function, insomnia, activities of daily living, ICU stay, hospital stay and hospital mortality will be collected during the hospital stay and at 1 month after discharge.

ETHICS AND DISSEMINATION

The study has been approved by the Ethics Committee of Zhongshan Hospital, Fudan University (B2024-076R). The results of this study will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT06346613.

Epidemiology of the COVID-19 pneumonia in a group of hospitals from Madrid-Spain during the full period of the State of Alarm HM cohort

INTRODUCTION

To describe the epidemiology pattern of the COVID-19 pandemic during all Spanish State of Alarm.

METHODS

Retrospective, observational, cohort and multicenter study. Inclusion criteria: age ≥18 years old, admitted for COVID-19 pneumonia in any of the centers of the HM Hospitals Group. Exclusion criteria: voluntary discharge, death in the emergency department, transfer to centers outside the HM group or incomplete data. State of Alarm period: 31/01/2020 to 05/07/2023. Predominant COVID-19 variant was defined when it exceeded 50% of the total isolates.

RESULTS

During the study period, 2,992 patients were admitted due to a COVID-19 pneumonia, 295 patients (9.86%) non-survive. Survivors and non-survivors were different in age and comorbidities. However, both cohorts presented a similar net of interaction between comorbidities. Hospital admissions per week showed an evolution in "peaks" with "troughs". A total of 197 (6.48%) patients were admitted to the ICU, of whom 52 (26.39%) non-survive; this subgroup stood out for having a higher proportion of septic shock, orotracheal intubation and acute renal failure, as well as a lower proportion of pulmonary thromboembolism and delirium. Concerning the viral variants, the incidence for the original variant was 4.05 cases/day, for the alpha variant 3.82 cases/day, for the delta variant 1.16 cases/day and for the omicron variant 1.35 cases/day.

CONCLUSION

Almost 1 of 10 patients with COVID-19 pneumonia death, a proportion that increased to 1 of 4 in case of being admitted to the ICU. Unexpectedly, interaction between comorbidities did not differ between survivors and non-survivors patients. Predominant variants were associated with different hospital admission rates but not influence the presence of peak-troughs evolution of the pandemic.

Etomidate in Severe Cushing Syndrome: A Systematic Review

Background

Severe Cushing syndrome is a medical emergency. Etomidate is the only IV option available for treating hypercortisolism, especially in critically ill patients obviating oral medications.

Methods

A systematic review and meta-analysis were conducted on the use of etomidate in the treatment of severe Cushing syndrome. This was registered in PROSPERO, and data reporting was done as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Thirty-six published articles comprising 76 clinical cases of 78 clinical episodes of etomidate use were included in the analysis for this review.

Results

Etomidate was administered safely to patients with ages ranging from 2 months to 82 years. It served as the first-line treatment in 53.2% of the cases, with 84.3% of patients treated in intensive care unit (ICU) settings. Infusion durations varied from 3 hours to 5.5 months, but 84.8% of treatments were completed in under 2 weeks. Faster cortisol reduction rates were observed in patients with higher baseline cortisol levels (P = .02), those receiving a prior bolus dose (P = .015), and those given higher initial infusion rates (P = .004). Etomidate as first-line therapy (P = .01) and in ICU settings (P < .01) were associated with more rapid cortisol reduction compared to its use as subsequent therapy or in non-ICU settings. Overall, 80.9% of patients survived to receive definitive treatment.

Conclusion

Etomidate is effective and safe for reducing cortisol levels in Cushing syndrome. There is a need for standardized guidelines on etomidate use, including detailed recommendations for different clinical settings and patient conditions to ensure safety and effectiveness.

Acute subdural hematoma from ruptured middle cerebral artery aneurysm: A rare and critical analysis of 25 cases

BACKGROUND

An acute subdural hematoma (aSDH) is a rare presentation of a ruptured intracranial aneurysm with pathophysiology and prognosis poorly defined. According to literature, prognosis might be improved with prompt diagnosis, hematoma evacuation and aneurysm treatment. The objective is to specify pathophysiology, prognostic factors and management of this pathology.

METHODS

We reported 23 cases of aSDH due to ruptured MCA aneurysm from literature revision and 2 cases from our center.

RESULTS

Median age was 51 years and 48% (12/25) were females. At their arrival, 76% (19/25) presented decreased level of consciousness and 55.55% (10/18) neurological deficits. Aneurysmal location was left MCA in 57.14% (8/14) and MCA segments were M4 in 76.92% (10/13) and bifurcation in 23.07% (3/13), median aneurysmal size was 6 mm, median hematoma size was 10 mm, median midline shift was 9 mm, aneurysmal projection and MCA concavity were anterior in 100% (3/3), subarachnoid hemorrhage (SAH) was present in 52.17% (12/23). The treatment was surgery in 84% (21/25), endovascular in 12% (3/25) and in 20% (5/25) decompressive craniectomy (DC) was necessary. Glasgow Outcome Scale (GOS) was >3/favorable in 66.66% (16/24) and death in 16.66% (4/2).

CONCLUSIONS

Anterior MCA concavity and aneurysmal projection might be related with aSDH presentation in proximal MCA aneurysms. We should suspect aneurysm origin when there is no history or stigma of trauma, and CT shows disproportionately massive aSDH. Hematoma evacuation solves the compressive mechanism which is the main cause of neurological deterioration in pure aSDH cases, because of that, immediate hematoma evacuation could justify better outcome in these patients.

Locating Femoral Vein by Anatomic Landmarks: A Cadaveric Study

BACKGROUND

In circumstances of emergency or challenging peripheral access, the femoral vein serves as a vital intravenous access channel. The vein is commonly located by palpating the femoral arterial pulse inferior to the mid-inguinal point or by the 'V' technique. As femoral arterial pulse may not be non-palpable in some cases, some distances from nearby anatomic landmarks might help to locate the femoral vein for cannulation.

MATERIALS AND METHODS

In 54 dissected cadaveric lower limbs, the distances of the femoral vein from the anterior superior iliac spine, the symphysis pubis, and the skin surface were measured to prepare a dataset for locating the vein with the help of these data. The values were statistically analyzed.

RESULT

The mean distance of the femoral vein from the anterior superior iliac spine was 80.16±8.96 mm, the mean distance from the symphysis pubis was 66.77±11.08 mm, and the mean depth of the femoral vein from the skin surface was 20.93±8.84 mm. All the distances and skin depths were higher in female limbs; however, only the depth from the skin surface was statistically significant across the genders.

CONCLUSION

These datasets might be useful as additional support while performing femoral vein cannulation in complicated and challenging cases where the facility of radiological monitoring is not available.

Intensive care unit patients' experiences of receiving music therapy sessions during invasive procedures: A qualitative phenomenological study

BACKGROUND

Excessive noise in intensive care units poses a significant challenge, impacting both patients and staff by elevating stress, disrupting recovery, and impeding effective communication among healthcare professionals. Despite the World Health Organization recommending noise levels below 35 dB, alarms in these units often surpass these limits, contributing to consistently high noise levels.

OBJECTIVES

The aim of this study is to explore intensive care unit patients' experiences with music therapy sessions during invasive procedures.

METHODS

This study was conducted using a qualitative hermeneutic phenomenological methodology grounded in Heideggerian philosophy. Interventions were conducted with a music therapist, and 14 in-depth interviews were collected. Reflexive inductive thematic analysis was performed.

RESULTS/FINDINGS

From the thematic analysis extracted from the 14 personal interviews, three themes were described that represent the bulk of the experiences and emotions of the study participants following the completion of the music therapy sessions. The most noteworthy results are described in the following, organised according to each theme: (i) music therapy against noise, sounds, and light; (ii) music therapy in the face of invasive tests and techniques; and (iii) music therapy as a strategy and tool.

CONCLUSIONS

Music therapy has significant potential to enhance the quality of life for patients in the intensive care unit. Music therapy can promote relaxation, reduce stress and anxiety, alleviate pain and discomfort, and improve emotional and physical wellbeing during patients' stay and invasive procedures.

Delirium as a Determinant of Long-Term Cognitive Dysfunction in the Context of Post-intensive Care Syndrome: A Prospective Study in a Latin American Environment

Introduction Cognitive dysfunction represents a major healthcare concern in the 21st century. Prolonged cognitive dysfunction and concomitant psychological and physical disorders in patients admitted to the intensive care unit (ICU) are components of the post-ICU syndrome (PICS). Notwithstanding the numerous published studies in this area, our work is the first to explore the relationship between PICS and delirium in the ICU in Uruguay. This research underscores the significance and potential of our study, which we believe will make a substantial contribution to this field of research in Latin America. Objectives The incidence rates of the cognitive, psychological, and physical sequelae constituting PICS were evaluated, and the relationships between these disorders and delirium in the ICU were studied. Methods This was a prospective cohort study in which patients were followed up for one year after admission to the ICU of Hospital Pasteur between 03/01/2017 and 05/31/2017. The pre-ICU condition of each patient was considered in the analysis. An initial telephone interview was conducted using the following scales: the Hamilton scale was used to assess anxiety, the Pfeiffer scale was used to assess cognitive impairment, and the Barthel scale was used to assess activities of daily living (ADLs). In a second face-to-face interview, the Mini-Mental State Examination (MMSE) and the Beck Depression Scale II (BDS-II) were used. Results Forty-three patients were divided into two groups: 15 (34%) with delirium in the ICU and 28 (66%) without delirium. The association of delirium with different sequelae was evaluated using the corresponding scales: Pfeiffer scale: Cognitive impairment was observed in 7/13 patients (53%) in the delirium group vs. 0/29 patients (0%) in the non-delirious group (p 0.001); MMSE score: Deterioration was observed in 6/7 patients (86%) in the delirium group vs. 1/7 patients (14%) in the non-delirious group (p 0.007). Cognitive impairment was found in 3/6 patients (50%) who presented with delirium in the ICU, while 1/8 patients (13%) who did not present with delirium experienced cognitive impairment (p = 0.036); Hamilton scale: Anxiety was found in 8/15 patients (57%) in the delirium group and 20/29 patients (68%) in the non-delirious group; BDS-II: Depression was found in 12/12 patients (100%) in the delirium group vs. 27/29 patients (93%) in the non-delirious group (p 0.57). Barthel scale: Dependence on others for ADLs was observed in 3/15 patients (20%) in the delirium group vs. 4/29 patients (14%) in the non-delirious group (p = 0.23). Conclusions Cognitive impairment was observed to be associated with delirium in the ICU, opening new avenues for research and possible treatment options. Although dependence on activities of daily living (ADLs) was more common in the delirium group, the difference between the two groups was not significant, highlighting the need for further research to understand the whole picture. Rates of anxiety and depression after ICU stay were also similar between the two groups, providing a baseline for comparison and informing future studies. The study highlights the urgent need for delirium-specific interventions in the ICU to address cognitive dysfunction and improve long-term outcomes in critically ill patients.

Current perspectives on the use of artificial intelligence in critical patient safety

Intensive Care Units (ICUs) have undergone enhancements in patient safety, and artificial intelligence (AI) emerges as a disruptive technology offering novel opportunities. While the published evidence is limited and presents methodological issues, certain areas show promise, such as decision support systems, detection of adverse events, and prescription error identification. The application of AI in safety may pursue predictive or diagnostic objectives. Implementing AI-based systems necessitates procedures to ensure secure assistance, addressing challenges including trust in such systems, biases, data quality, scalability, and ethical and confidentiality considerations. The development and application of AI demand thorough testing, encompassing retrospective data assessments, real-time validation with prospective cohorts, and efficacy demonstration in clinical trials. Algorithmic transparency and explainability are essential, with active involvement of clinical professionals being crucial in the implementation process.

Use of Point-of-Care Ultrasound for Central Line Placement: A Quality Improvement Project

OBJECTIVE

Point-of-care ultrasound (POCUS) is a reliable tool and is slowly being incorporated into neonatal care. Central line (CL) placement is the most common procedure in the neonatal intensive care unit. Radiographs remain the current standard to confirm the location of the central line tip (CLT). Catheters often need adjustments with multiple x-rays. A quality improvement (QI) project was designed to use POCUS and increase the percentage of CLs needing only 1 x-ray to confirm CLT location by 25% in 1 year.

METHODS

CLs placed between July 2021 and February 2024 were included. There were 3 key drivers: POCUS training, promoting POCUS acceptance, and standardizing the scanning process. The primary outcome was the percentage of CLs placed with POCUS that required only 1 x-ray to confirm placement. The secondary outcome was the number of inadvertently placed arterial peripherally inserted central catheters (PICCs). Process measures were the percentage of providers competent to use POCUS and the percentage of CLs inserted and checked with POCUS. Statistical process control charts were used for analysis.

RESULTS

Targeted interventions increased the percentage of CLs that needed only 1 x-ray from 35% to 57%. Forty-eight percent of providers were competent, and 47% of CLs were assessed by POCUS. Five PICCs were inadvertently inserted into an artery during the baseline vs zero after the interventions.

CONCLUSION

QI methodology and targeted interventions were associated with a reduction of x-rays in neonates requiring CL placement to confirm position and a reduction in the inadvertent arterial insertion of PICCs.

Profile of haemostasis and coagulation in patients with peritoneal carcinomatosis undergoing cytoreductive surgery with hyperthermal chemotherapy

BACKGROUND

One-third of patients with peritoneal carcinomatosis undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) present alterations in conventional coagulation test results. However, perioperative coagulation has not been systematically investigated in these patients. This study aimed to investigate hemostatic changes in such patients.

METHODS

This prospective observational study included patients with peritoneal carcinomatosis who underwent CRS-HIPEC. Variables of conventional coagulation and rotational thromboelastometry (ROTEM) parameters of patients who underwent CRS-HIPEC at baseline (time 0, T0: before surgery) were compared with those of healthy blood donors (HBD). Blood samples were collected at baseline (T0), 2-h (T2), and 72-h (T72) after surgery.

RESULTS

44 patients who underwent CRS-HIPEC and 40 HBDs were included. At T0, patients who underwent CRS-HIPEC presented with lower hemoglobin levels and elevated C-reactive protein, fibrinogen, factor XIII (FXIII), and D-dimer levels than HBDs. At T2, significant decreases in hemoglobin, platelet count, fibrinogen, and FXIII levels were observed. In contrast, D-dimer and von Willebrand factor levels increased. Regarding ROTEM parameters, in the postoperative period, increased clotting time in thromboelastometry with extrinsic activation, and maximum clot firmness in thromboelastometry with fibrin contribution, along with a significant decrease in maximum clot firmness in thromboelastometry with extrinsic activation without a hyperfibrinolysis pattern, were observed. Platelet function, as assessed using the platelet function assay, was normal.

CONCLUSIONS

CRS-HIPEC causes coagulopathy secondary to a pronounced platelet drop, worsening of fibrinogen and FXIII levels, and impaired clot firmness as evidenced by ROTEM. A proinflammatory status was ubiquitously observed.