PharmacotherapyBokai Zhao, Ye Shen, Kelli Henry, John W Devlin, David J Murphy, Susan E Smith, Brian Murray, Sandra Rowe, Andrea Sikora
BACKGROUND: The 2019 medication regimen complexity-intensive care unit (MRC-ICU) score is associated with patient outcomes, ICU complications, and critical care pharmacist workload. This score was developed using heuristic component selection and validated in a single-center cohort of 130 ICU patients. We sought to apply data-driven reweighting methodology in a large, multicenter cohort of ICU adults to improve the predictive capabilities of MRC-ICU. METHODS: This was a retrospective, observational cohort study of adults admitted to an ICU between 2015 and 2023 at two academic health systems. Machine learning-based methods, including Principal Component Analysis and Random Forest, were used to create an updated MRC-ICU score optimized to predict three outcomes: hospital mortality, ICU fluid overload (FO) occurrence, and invasive mechanical ventilation (IMV) use. MRC-ICU 2.1 used average mortality, FO, and IMV use; MRC-ICU 2.2 used average mortality and FO and adjusted for prolonged IMV use. Data from one center were used for training and testing, and data from the other for validation. The predictive abilities of MRC-ICU 2.1 and 2.2 for each outcome were compared to MRC-ICU 1.0 and to severity of illness scores (i.e., Acute Physiology and Chronic Health Evaluation [APACHE] II and Sequential Organ Failure Assessment [SOFA]). RESULTS: A total of 19,117 patients across training, testing, and validation datasets were included. MRC-ICU 2.0 scores outperformed MRC-ICU 1.0 for predicting most outcomes, with improvements in Area Under the Receiver Operating Characteristic (AUROC) ranging from +0.03 to +0.08 across datasets. MRC-ICU 2.1 and 2.2 did not consistently outperform APACHE II and SOFA in predicting mortality. The addition of MRC-ICU 2.0 scores to models including APACHE II or SOFA resulted in statistically significant improvements in discrimination in several settings (DeLong p < 0.05), with AUROC increases generally ranging from approximately +0.01 to +0.13 depending on outcome and dataset. CONCLUSIONS: The updated MRC-ICU 2.0 score (MRC-ICU 2.1 and 2.2) demonstrated consistently improved discrimination compared with the original MRC-ICU 1.0 across outcomes and datasets. The performance of MRC-ICU 2.0 (MRC-ICU 2.1 and 2.2) was generally comparable to established severity-of-illness scores (SOFA and APACHE II), although it did not consistently outperform these measures. When incorporated into combined models, MRC-ICU 2.0 provided additional predictive value, indicating that it captures information complementary to traditional severity-of-illness scores. Overall, these findings suggest that MRC-ICU 2.0 represents an improved and clinically interpretable measure of medication regimen complexity that is useful as a complementary predictor.
Journal of human nutrition and dietetics : the official journal of the British Dietetic AssociationTerpsichori Karpasiti, Qinglin Jin, Kevin Whelan, Danielle Bear
INTRODUCTION: Nutritional management of critically ill patients receiving vasopressors is challenging. This survey aimed to describe UK critical care dietitians' practices and confidence regarding the route, timing and dose of artificial nutrition support in critically ill patients receiving vasopressors, and explore relationships of these with intensive care unit (ICU) and dietitian professional characteristics. METHODS: A cross-sectional, anonymous survey was distributed electronically to UK registered dietitians working in ICU via the British Dietetic Association Critical Care Specialist Group and British Society of Parenteral and Enteral Nutrition mailing lists. The 32-item survey included questions regarding ICU and professional characteristics, dietetic practices (artificial nutrition route, timing, and dose), evidence sufficiency and confidence. Data were compared between ICU and professional characteristics and dietetic practice using Fisher's exact or Kruskal-Wallis tests, as appropriate, and with self-reported confidence using Spearman's rank correlation or Kruskal-Wallis. RESULTS: Of 89 responses, 72 met the eligibility criteria. All respondents completing dietetic practice questions (71/71, 100%) used gastric feeding as the first-line artificial nutrition route, and two thirds (47, 66.2%) initiated this within 24-48 h of ICU admission. Over two thirds (39/57, 68.4%) aimed for < 70% energy targets in the first 72 h, with 48 (84.2%) escalating to full targets thereafter. Despite more than three quarters (41/52, 78.8%) feeling confident in managing critically ill patients receiving vasopressors, most considered evidence to be insufficient. There was no significant association between enteral nutrition practices and any ICU or dietitian professional characteristics or self-reported confidence. CONCLUSION: Amongst UK critical care dietitians, there is substantial variation in EN initiation and escalation practices for critically ill patients receiving vasopressors. Despite high self-reported confidence, evidence concerning the route, timing and dose of artificial nutrition was perceived insufficient.
Acta anaesthesiologica ScandinavicaShira K Hendin, Rasmus P Beske, Jesper Kjaergaard, Jacob E Møller, Henrik Schmidt, Simon Mølstrøm, Simon Schneekloth, Martin A S Meyer, Laust E W Obling, Chris…
BACKGROUND: Hemodynamic management after out-of-hospital cardiac arrest (OHCA) is critical, yet the impact of vasopressor-driven mean arterial pressure (MAP) targets on pulmonary circulation and right ventricular (RV) function remains unclear. METHODS: In this substudy of the randomized, double-blinded BOX trial, comatose OHCA survivors were allocated to low (63 mmHg) or high (77 mmHg) MAP targets. Pulmonary artery catheters (PAC) were used for serial hemodynamic assessment for 48 h after Intensive Care Unit admission. The primary endpoint was calculated pulmonary vascular resistance (PVR), secondary endpoints included pulmonary capillary wedge pressure (PCWP), pulmonary artery pulsatility index (PAPi), and RV cardiac power output (RV-CPO)-a measurement of RV pumping function. RESULTS: Among 730 included patients (median time randomization to PAC insertion 1.3 h), mPAP was consistently higher in the high-MAP group (mean difference 1.11-1.71 mmHg, 95% CI range 0.12-2.59). Calculated PVR was transiently lower in the high-MAP group during the first 24 h (mean difference -0.16 to -0.30, 95% CI range -0.31 to 0.11), before converging between groups. RV-CPO was lower in the low-MAP group throughout the observation period (mean difference 0.01-0.04 W [95% range 0.00-0.07], with the largest difference at 48 h. PCWP decreased in both groups but was significantly lower in the low-MAP group during the first 12 h (mean difference 1.06-1.40 mmHg, 95% CI range 0.25-2.38). CONCLUSIONS: In comatose OHCA survivors, targeting a higher MAP increased pulmonary artery pressures, PCWP, RV-CPO, heart rate, and cardiac output. The proportionally greater increase in cardiac output over pulmonary artery pressures resulted in a decreased calculated PVR. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03141099. EDITORIAL COMMENT: In this secondary analysis of a subgroup in the BOX out of hospital cardiac arrest treatment trial for oxygen level targets, blood pressure treatment target levels, higher or lower were analyzed, including central circulatory outcomes, using a pulmonary artery catheter. The higher blood pressure target group had accompanying higher pulmonary artery pressures and cardiac output, with initially a small reduction in calculated pulmonary vascular resistance.
Acta anaesthesiologica ScandinavicaSofie Bay Nøsted, Frederikke Stenner Falkvist, Martin Schønemann-Lund, Morten Bestle, Sine Wichmann
BACKGROUND: Acute kidney injury (AKI) is common in the intensive care unit (ICU) and associated with increased mortality. While diuretics are widely used to manage fluid accumulation, their impact on survival in established AKI remains uncertain. METHODS: This retrospective cohort study included adult ICU patients with AKI present on or within 48 h of ICU admission in the Capital Region of Denmark, 2022-2024. Early diuretic exposure was defined as systemic diuretic administration within 24 h after AKI onset. Primary outcome was 30-day mortality, analyzed using 24-h landmark Cox regression adjusted for sex, Simplified Acute Physiology Score 3 (SAPS 3), baseline creatinine, and AKI stage. Pre-specified subgroup analyses by AKI stage and post hoc sensitivity analyses were performed. Secondary outcomes included fluid accumulation (> 5% ideal body weight) and Major Adverse Kidney Events within 30 days (MAKE30). RESULTS: Of 4430 patients with AKI, 58% received early diuretics. In the primary adjusted analysis, early diuretics were not associated with 30-day mortality (hazard ratio (HR) 1.11, 95% confidence interval (CI) 0.98-1.26, p = 0.113). In a post hoc time-dependent sensitivity analysis, diuretic use was associated with higher mortality (HR 1.27, 95% CI 1.08-1.49, p = 0.004). In the pre-specified AKI stage 3 subgroup, early diuretic use was associated with a higher risk of mortality (HR 1.42, 95% CI 1.16-1.73, p < 0.001). Diuretics were associated with a lower risk of fluid accumulation (odds ratio (OR) 0.58, p < 0.001) but a higher risk of MAKE30 (OR 1.23, p = 0.004). CONCLUSION: Early diuretic treatment was frequent but not associated with improved survival in the primary analysis. Given the observational design, causal relationships cannot be inferred from these findings. These results do not support routine early diuretic use in unselected AKI patients; prospective studies are needed to clarify the role of targeted diuretic therapy in patients with fluid accumulation. EDITORIAL COMMENT: This retrospective cohort analysis analyzes associations between acute renal injury development in intensive care unit patients and early diuretic use, along with fluid balance. Early diuretic use was not associated with improved survival in this cohort, where treatments were uncontrolled. Risks are described by renal injury severity subgroups and renal outcomes after ICU.
Acta anaesthesiologica ScandinavicaAnniken Maamoen, Kristina Bondjers, Anne K Langerud, Grete A Dyb, Synne Ø Stensland, John A H Zwart, Leiv A Rosseland, Jan O Christensen, Solveig K Reitan, Dan…
BACKGROUND: Turnover among healthcare workers (HCWs) is highly prevalent in intensive care units (ICUs). Due to demanding workloads, stressful conditions, and increasing pressure to work more efficiently, this problem is likely to persist. Consequently, implementing proactive strategies to support HCWs retention is needed. This study aimed to examine associations between work environment factors and ICU HCWs' intentions to quit. METHODS: Based on data from a prospective, open-cohort, multicenter study of hospital frontline workers conducted during the four main waves of the COVID‑19 pandemic in Norway, we analyzed self-reported data from HCWs who completed the final survey, which included two outcomes relevant to turnover: (1) frequent thoughts of quitting and (2) intention to look for a new job. A work-environment -factor tool assessing occupational risk and characteristics in emergencies (FORCE-index). Hierarchical linear regression was used to examine associations between work environment factors and the two turnover outcomes. RESULTS: Among 977 frontline HCWs (median age 45 years, 75% women, median 16 years of work experience), several work environment factors showed protective association with turnover intention. Across both outcomes, familiarity with colleagues and surroundings and social support from colleagues and immediate superiors were the most important protective factors, linked to fewer thoughts of quitting and a lower intention to seek a new job. For frequent thoughts of quitting, additional protective factors included better stress management, workload manageability, infection safety, and social safety. Younger age was a consistent risk factor for both outcomes, while working in the ICU and experiencing morally distressing situations were specifically associated with thoughts of quitting. Pandemic exposure variables were not significantly associated with either outcome. CONCLUSION: Turnover intention among ICU HCWs at four Norwegian university hospitals during the fourth time point of the COVID‑19 pandemic was associated with work environment factors. Work in the ICU, younger age, and morally distressing experiences were associated with frequent thoughts of quitting, whereas several work environment factors were protective. Familiarity and social support were also protective against actively looking for a new job, suggesting that strengthening these factors may be particularly important for reducing turnover intention and retaining HCWs in the ICU.
Acta anaesthesiologica ScandinavicaVera Crone, Morten Hylander Møller, Anders Granholm, Anders Perner, Waleed Alhazzani, Laura Rindom Krogsgaard, Abdulrahman Al-Fares, Johanna Hästbacka, Marlies…
BACKGROUND: Feeding intolerance is common in intensive care unit (ICU) patients, but evidence supporting prokinetic use is limited. We aimed to provide international epidemiological data on the use of prokinetic agents in adult ICU patients and to explore potential associations with patient-important outcomes. METHODS: We conducted an inception cohort study between August 2024 and March 2025 in acutely admitted ICU patients in 56 ICUs across 11 countries. The primary outcome was the proportion of patients receiving prokinetic agents. Secondary outcomes included associations with baseline characteristics, serious adverse events (SAEs), days alive out of ICU/hospital, days alive without life support and 90-day mortality. Associations with SAEs, baseline characteristics and mortality were assessed using pre-specified Cox regression models, while other secondary outcomes were evaluated using adjusted linear regression. All models were adjusted for country, severity of illness, number of comorbidities, surgery and ICU admission type. RESULTS: Among 1440 ICU patients (median age 64 years, 56.9% male), 187 (13.0%; 95% confidence interval [CI] 11.3-14.8) received prokinetic agents during ICU stay, most commonly metoclopramide (65%). Prior abdominal surgery was associated with the initiation of prokinetic agents (hazard ratio [HR] 1.81; 95% CI 1.17-2.79). Use of prokinetic agents was statistically significantly associated with a higher hazard of experiencing a SAE (HR 1.9; 95% CI 1.3-2.8), fewer days alive out of ICU (mean difference [MD] -7.6 days; 95% CI, -13.4 to -2.2) and hospital (-13.5 days; 95% CI -18.7 to -8.4), but not with 90-day mortality (HR 0.62; 95% CI 0.3-1.2). CONCLUSIONS: Prokinetic agents were used in 13% of ICU patients, most commonly metoclopramide and more often in those with prior abdominal surgery. Prokinetic use was associated with a higher hazard of experiencing SAEs and fewer days alive out of hospital/ICU.
The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal ObstetriciansDilly O C Anumba, Cath M Harrison, Gian Carlo Di Renzo
AIM: Preterm birth, defined as delivery at gestational age less than 37 weeks, is a major contributor to neonatal morbidity, placing a significant burden on healthcare resources. This analysis explores the prevalence and patterns of critical care admissions among preterm neonates in England. METHODS: Hospital-level data were obtained from the Hospital Episode Statistics Data-NHS England 2022-2023 database. Data were analyzed for newborns in England for April 2022-March 2023, focusing on gestational age categories and the care level of facilities managing these infants. RESULTS: Among all 541,765 singleton births in England during the examined interval, 7.0% (37,815) were preterm. Of these preterm infants, 71.3% (26,965) had a recorded gestational age. Of those with recorded gestational ages, 0.6% (149) were born <28 weeks (extremely preterm), 10.5% (2,844) at 28-32 weeks (very preterm), and 88.9% (23,972) at 33-37 weeks (moderate and late preterm). While 58.4% (87) of extremely preterm neonates were delivered in a hospital with appropriate facilities, 32.2% (48) of extremely preterm neonates, and 4.3% (121) of very preterm neonates were born in hospitals without neonatal intensive care facilities. CONCLUSION: Persistent gaps in triage for women at risk of preterm birth highlights the need for improved early risk recognition and in utero referral systems to ensure appropriate delivery in recommended critical care facilities and to reduce postnatal transfers for babies.
Computers, informatics, nursing : CINSu-Jin Jeong, Shin-Jeong Kim
Accurate and timely mortality prediction is essential for nursing clinical decision-making in intensive care units (ICUs). Although the Sequential Organ Failure Assessment (SOFA) score is widely used to evaluate organ dysfunction, its manual calculation limits routine application in fast-paced clinical environments. This study aimed to enhance ICU system-level safety and workflow efficiency by refining and evaluating an automated Electronic Medical Record (EMR)-integrated SOFA scoring system (AI-SOFA) to evaluate: (1) its predictive performance for mortality compared to traditional manual scoring; and (2) its clinical utility as a nursing informatics initiative. A retrospective cohort study was conducted using EMR data from 2559 ICU admissions at a tertiary hospital in South Korea. Automated SOFA scores were generated using 11 routinely collected clinical parameters. Logistic regression, random forest, and XGBoost models were trained, and model performance was evaluated using the area under the receiver operating characteristic curve (AUROC), sensitivity, specificity, accuracy, and F1 score. ICU mortality increased markedly with higher SOFA scores, exceeding 50% at scores ≥13. Among the machine learning (ML) models, XGBoost demonstrated the highest predictive performance (AUROC=0.9005), outperforming random forest (0.8975) and logistic regression (0.8722). In contrast, mortality prediction based on manual SOFA scoring showed substantially lower accuracy (AUROC=0.64). The AI-SOFA system serves as a nursing informatics tool that supports nursing workflows by enabling real-time risk stratification, reducing documentation burden, and facilitating timely clinical decision-making in ICU settings.
BACKGROUND: The United States declared endemic measles eliminated in 2000. However, outbreaks continued, with resurgences in 2019 and 2025. In 2025, more than 2200 cases across 48 outbreaks, the most since 1992, were reported. In the first half of 2026, 2073 cases were reported. Declining measles, mumps, and rubella vaccination rates have increased susceptibility among children. Acute and critical care nurses are central to early recognition and management of measles for optimal outcomes. OBJECTIVE: To summarize current evidence on measles epidemiology, pathophysiology, clinical presentation, complications, treatment strategies, and acute and critical care nursing implications, emphasizing preparedness amid rising case numbers. METHODS: A literature review was conducted using PubMed and CINAHL databases and websites of Centers for Disease Control and Prevention, World Health Organization, professional organizations, and pediatric hospitals. English-language sources published from 2015 to August 2025 were prioritized; relevant earlier studies were included. Reference lists were searched for additional articles. DATA SYNTHESIS: Measles is among the most contagious human diseases. Typical features include fever, cough, coryza, conjunctivitis, and morbilliform rash. Severe respiratory and neurological complications may require critical care hospitalization. Complications like encephalitis may present weeks to years after acute infection. Management remains supportive, with vitamin A supplementation recommended. Acute and critical care nursing priorities include early recognition, isolation precautions, specimen collection, respiratory and hemodynamic support, neurological monitoring, serial assessments, hydration, nutrition, and caregiver education. CONCLUSION: Measles is resurging in the United States despite being vaccine preventable. Nurse preparedness, including knowledge of clinical features, complications, and infection control, is essential to mitigate morbidity and mortality and to support outbreak prevention. (Critical Care Nurse. Published online ahead of print July 17, 2026).
INTRODUCTION: Critical care nursing includes physically, emotionally, and ethically challenging jobs which can induce role conflict and organizational cynicism amongst other organizational attitudes. This research aimed to evaluate the association between role conflict and organizational cynicism among critical care nurses. METHODS: This cross-sectional study recruited 322 nurses working in intensive care units of hospitals under Tehran University of Medical Sciences who completed Role Conflict Questionnaire by Rizzo et al., and Organizational Cynicism Questionnaire by Dean et al. The data were analyzed through Spearman correlation test and multiple linear regression analysis. RESULTS: The mean age of participants was 36.26 ± 8.61, and 73.6% were women. Role conflict had a mean score of 2.58 ± 0.83 and organizational cynicism of 2.73 ± 0.96, showing moderate level of both variables. A significant positive correlation was found between role conflict and organizational cynicism (r = 0.765, p < 0.01) as well as with its emotional, cognitive, and behavioral components. Multiple job holding and number of workplaces at one time were identified as the main factors for both variables. CONCLUSION: There exists a high association between role conflict and organizational cynicism among critical care nurses. CLINICAL TRIAL NUMBER: Not applicable.
JMIR research protocolsAna Karolina Ibanhes, Pryscilla Kathiana Maia Freitas da Silveira Redigolo, Anna Alicia Pereira Duarte, Anna Letícia Pereira Duarte, Carolina Mariano Pompeo
BACKGROUND: Cerebrovascular diseases represent a major public health challenge, and stroke is among the leading causes of mortality worldwide. Among poststroke complications, pneumonia stands out because of its frequency and negative impact on clinical outcomes, including prolonged hospitalization and increased mortality. In this context, studies investigating the risk factors associated with stroke-related pneumonia differ in terms of their design, care setting, and adopted definitions. OBJECTIVE: This study aims to map risk factors related to the incidence of pneumonia in adults hospitalized after stroke. METHODS: This scoping review protocol was developed in accordance with the JBI Reviewer's Manual and the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews). Searches will include the following indexed databases: PubMed (MEDLINE), Embase, Scopus, the Cochrane Library, Web of Science, and the Virtual Health Library. Gray literature will be searched in Google Scholar, the CAPES Theses and Dissertations Catalog, the Brazilian Digital Library of Theses and Dissertations, ProQuest, SciELO Preprints, medRxiv, ClinicalTrials.gov, and the Brazilian Registry of Clinical Trials. Additional organizational sources will include the World Health Organization, the Pan American Health Organization, the Centers for Disease Control and Prevention, the European Stroke Organisation, and the Brazilian Ministry of Health. Qualitative, quantitative, and mixed methods studies, including observational and experimental designs, will be considered, with no language or time restrictions, provided that they meet the eligibility criteria defined in the protocol. Study selection will follow 3 stages using Mendeley (Elsevier) and Rayyan (Rayyan Systems Inc). RESULTS: This protocol was funded in June 2026 by the Federal University of Mato Grosso do Sul and the Coordination for the Improvement of Higher Education Personnel (Finance Code 001). The protocol was developed and prospectively registered in the Open Science Framework. Preliminary searches were carried out in August 2025 in PubMed (MEDLINE), Embase, and the Cochrane Library to test the sensitivity of the search strategies and estimate the potential volume of eligible studies. At the time of publication, the final search, study selection, data extraction, and evidence synthesis had been completed. The manuscript reporting the final review results is expected to be submitted for publication in early 2027. CONCLUSIONS: This review is expected to contribute to the systematization of evidence on risk factors related to stroke-associated pneumonia, identify knowledge gaps, and support future prevention strategies and clinical management of hospitalized patients. TRIAL REGISTRATION: Open Science Framework 10.17605/OSF.IO/EXYWZ; https://osf.io/exywz/overview. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/90248.
Medizinische Klinik, Intensivmedizin und NotfallmedizinTilo Zimmermann, Lars Krüger, Franziska Wefer, Peter Nydahl, Marius Ostermöller, Lisa Peper, Daniel Plaß, André Ramos Y Soto, Richard Schalk, Valery Maurice Ki…
Enfermeria intensivaEdna Margarita Osorio-Durán, Mónica López de-Ávila, Jennifer Rojas-Reyes, Wilson Cañon-Montañez, Alba Luz Rodríguez-Acelas
INTRODUCTION: Spirituality, recognized as an essential aspect of nursing care, contributes to well-being and resilience in critical care settings. Its integration into practice strengthens the meaning and sense of meaning and purpose in the lives of nursing professionals. OBJECTIVE: To systematically review the evidence on spirituality among nursing professionals working in critical healthcare settings. METHODOLOGY: A systematic review and meta-analysis were conducted following the PRISMA guidelines. The protocol was registered in PROSPERO (CRD42023371984). Searches were performed from inception to april 2024 in the following databases: Medline/PubMed, Embase, Lilacs, Cochrane CENTRAL, and Web of Science. The meta-analysis of individual means was performed using a random-effects model. Untransformed means (MRAW) were used to estimate the 95% confidence intervals of individual studies, while the I2 and tau2 statistics assessed heterogeneity. RESULTS: A total of 1175 studies were identified, 34 of which were included in the systematic review and 4 in the meta-analysis. A prevalence of 58,8% was observed in non-experimental quantitative studies, with "spirituality education and meeting spiritual needs" being the main theme. Meta-analyses were conducted on studies using scales to assess spirituality levels, particularly the Spiritual Care Competence Scale (SCCS), which showed the best performance with an MRAW of 98,56 (IC 95%: 97,86; 99,25; I2: 0,0%), indicating a moderate level of competence in spiritual care. CONCLUSIONS: The findings highlight the importance of spirituality in professional performance in critical care settings, emerging as a key component for promoting well-being by strengthening resilience in the face of caregiving challenges.
Molecular medicine reportsLing Wei, Xiaohua Kong, Yuying Li, Huixia Wu, Yirong Gan, Fang Sun
Feeding intolerance (FI) is a common and debilitating challenge among critically ill patients that is linked to a pathway involving the collapse of the gut microbial ecology. The present review synthesizes multiomics evidence supporting a framework whereby critical illness‑associated gut dysbiosis results in a functional deficit of a microbially derived short‑chain fatty acid butyrate, a pivotal metabolite involved in maintaining intestinal barrier integrity, immuneoregulation and gastrointestinal motility. The loss of butyrate‑producing bacteria and their genetic pathways is strongly correlated with FI and may represent a contributory pathogenic mechanism. Key butyrate‑producing organisms diminished during this process include Faecalibacterium prausnitzii and Roseburia spp. Building upon this mechanistic framework, a pragmatic, nurse‑driven intervention model aimed at preserving and restoring microbial health in critically ill patients was proposed. This model is founded on four principal strategies: Minimizing iatrogenic harm (such as antibiotic/proton pump inhibitor stewardship), targeted microbiota nourishment (pre/synbiotics), cautious microbial restoration (probiotics/fecal microbiota transplantation) and innovative monitoring approaches. By integrating principles of microbial ecology with clinical nursing science, the present review provides a framework for developing nurse‑driven protocols designed to address the underlying pathophysiology of FI and improve patient outcomes.
Artificial intelligence in medicineYuxiao Cheng, Xinxin Song, Ziqian Wang, Qin Zhong, Kunlun He, Jinli Suo
The rapid evolution of deep learning is revolutionizing critical care medicine by enabling highly accurate early warning systems. These systems are capable of predicting diverse clinical deteriorations, including acute kidney injury, myocardial infarction, and circulatory failure. While demonstrating strong predictive capabilities, conventional deep learning models face two fundamental limitations in clinical implementation: their opaque decision-making processes and limited generalizability across diverse patient populations and care environments. To address these challenges, we present a causally-informed deep learning framework that integrates causal discovery to jointly identify the causal drivers of clinical outcomes alongside prediction. This approach yields two unique advantages: demonstrating the explicit interpretation of the prediction while exhibiting decent performance when applied to unfamiliar environments. Benefiting from these features, our approach achieves superior accuracy across six different critical deteriorations and also demonstrates improved generalizability across diverse patient groups compared to various baseline algorithms. Besides, we provide explicit causal pathways to serve as references for assistant clinical diagnosis and potential interventions. By incorporating causal reasoning into clinical prediction, our approach can enhance clinical decision support through both reliable forecasting and transparent physiological interpretation, paving the way for more trustworthy AI implementation in critical care.
Journal of biomedical informaticsDaniel J Tan, Jiayang Chen, Dilruk Perera, Kay Choong See, Mengling Feng
OBJECTIVE: Enteral nutrition (EN) delivery in the ICU remains suboptimal due to limited personalization and uncertainty regarding appropriate calorie, protein, and fluid targets under dynamic metabolic demands. We introduce DeepEN, a reinforcement learning (RL) framework for personalized EN optimization using electronic health record data. METHODS: DeepEN was trained on over 11,000 ICU patients from MIMIC-IV to generate 4-hourly, patient-specific caloric, protein, and fluid targets. The state representation incorporated demographics, comorbidities, vital signs, laboratory values, and recent interventions. A physiologically aligned reward framework balanced biomarker stability with long-term survival. Policy learning employed a dueling double deep Q-network with Conservative Q-Learning regularization to enable safe offline training. RESULTS: DeepEN achieved the highest estimated policy value (Vπ=9.48) and the lowest calibrated mortality (18.8 ± 1.0%), representing a 4.0 percentage-point absolute reduction compared with clinician practice (22.8%). The policy also demonstrated superior metabolic stability, achieving the highest proportion of glucose, phosphate, and sodium values within target range. Furthermore, deviation from the DeepEN policy was independently associated with increased mortality and biomarker instability, whereas deviation from a random policy showed no such association. Interpretability analyses further indicated that recommendations were conditioned on physiologically relevant markers of organ function and metabolic status rather than static dosing heuristics. CONCLUSION: DeepEN demonstrates the feasibility of conservative offline RL for safe, individualized EN optimization, highlighting the potential of data-driven personalization to complement guideline-based approaches in critical care.
Cardiology clinicsOmar Y Fakhreddine, Seulgi E Kim, Andrew B Civitello
Durable left ventricular assist devices (LVADs) have transformed the management of advanced heart failure, but early post-operative management remains a time of heightened vulnerability with disproportionate impact on short-term and long-term outcomes. This article provides a practical, physiology-driven framework for intensive care unit (ICU) management following LVAD implantation, emphasizing early hemostasis and anticoagulation strategies, systematic hemodynamic assessment, and optimization of right ventricular function. Additional sections address respiratory management, dysrhythmia control, nutrition, and early mobilization as essential components of recovery. By synthesizing contemporary evidence with bedside decision-making, this guide aims to support multidisciplinary ICU teams in standardizing care.
Cardiology clinicsMegan H Hicks, Suneeta K Acharya, Karuna Puttur Rajkumar, John P Gaillard, Ettore Crimi, Ashish K Khanna
In the cardiovascular intensive care unit (CVICU), hemodynamic monitoring provides the foundation for evaluating tissue perfusion, guiding fluid resuscitation, titrating vasoactive medications, and assessing response to therapy. However, the optimal approach to hemodynamic monitoring remains a subject of ongoing debate. This article highlights the nuances of hemodynamic monitoring in the CVICU and reviews both established and emerging technologies and how they may be combined with clinical judgement to optimize patient outcomes for the critically ill patients.
International journal of nursing studies advancesSara Rahimi, Mojtaba Senmar, Mohammad Mozafari, Mahdie Bahrami, Rahman Panahi, Marzieh Khatooni
BACKGROUND: Spiritual care is a core element of holistic nursing, especially in demanding settings such as emergency and intensive care units where patients often face life-threatening conditions and end-of-life challenges. Despite its importance, little is known about nurses' competence in providing spiritual care and the factors that shape it. OBJECTIVE: This study aimed to explore spiritual care competence and its predictors among nurses working in critical and emergency settings. DESIGN: A cross-sectional study. SETTINGS: The study was conducted in the emergency and intensive care units of two central hospitals in Qazvin, Iran. PARTICIPANTS: A total of 180 nurses working in critical care and emergency units participated in the study. METHODS: Data were collected using the Spiritual Care Competence Scale, the Spiritual Intelligence Self-Report Inventory, and the Death Attitude Profile-Revised. Descriptive statistics and logistic regression analyses were performed using SPSS version 23. RESULTS: Nurses demonstrated moderate levels of spiritual care competence (86.79 ± 4.25) and spiritual intelligence (57.15 ± 6.13). Among death attitude dimensions, neutral acceptance scored highest, while approach acceptance scored lowest. Logistic regression revealed that age, work experience, spiritual intelligence, and a positive attitude toward death were significant predictors of spiritual care competence (p < 0.05). CONCLUSION: Spiritual care competence among nurses is associated with personal maturity, professional experience, spiritual intelligence, and positive attitudes toward death. Integrating spiritual care education and fostering positive perspectives on death may enhance nurses' preparedness to deliver comprehensive, patient-centered care.
Cardiology clinicsAmy L Friedman, Marissa W Mery, Christina A Jelly, Bret D Alvis
Heart transplantation is the definitive treatment for end-stage heart failure. Post-transplant care is dynamic and complex, requiring a thoughtful multidisciplinary approach. Invasive hemodynamic monitoring is central to guiding inotrope and vasopressor titration to optimize allograft function and end-organ perfusion. Vigilant assessment for primary graft dysfunction is essential and informs escalation to mechanical circulatory support when needed. As hemodynamics and graft function stabilize, patients are liberated from mechanical ventilation, volume status is optimized, nutrition and mobility are prioritized, and pharmacologic and mechanical supports are weaned. Concurrently, immunosuppression is titrated and patients are monitored closely for infection.