Nursing in critical careBruna Cristina Velozo, Aglecia Moda Vitoriano Budri, Larissa Cassiano Bernardo, Meire Cristina Novelli E Castro, Gabriela Dos Santos Cruz, Geovana Rodrigues Go…
BACKGROUND: The lack of consensus on the best pressure injury (PI) risk assessment tools demonstrates the need for further comparative research to identify the most effective options for intensive care unit (ICU) populations. AIM: This study compared the predictive validity and reliability of five PI risk assessment tools in adult ICU patients. STUDY DESIGN: A prospective cohort study was conducted with patients aged ≥ 18 years, admitted to the ICUs for at least 24 h and without pre-existing PI. Five tools (Braden Scale, CALCULATE, Cubbin & Jackson, EVARUCI and Sunderland) were used daily to assess PI risk until either a PI developed or the participant was discharged, died or completed 21 days in the ICUs. The main outcome measures included area under the receiver operating characteristic (ROC) curve, sensitivity, specificity, relative risk and reliability. RESULTS: Of the 150 participants, 40 (26.7%) developed PIs. None of the five tools demonstrated good predictive accuracy. AUC values ranged from 0.605 to 0.692 across the five tools, with none exceeding the predefined threshold of 0.70. Participants classified as high risk by Sunderland, Cubbin & Jackson and EVARUCI had a 3.0, 2.5 and 2.1 times higher risk, respectively, of developing a PI. Cubbin & Jackson was the only tool to achieve acceptable reliability values in Cronbach's alpha, intraclass correlation coefficient (ICC) and Cohen's weighted kappa. CONCLUSIONS: High-risk classification using the Sunderland, Cubbin & Jackson and EVARUCI scales was more strongly associated with subsequent PI development than classification using the other tools. Reliability findings varied across parameters, with Cubbin & Jackson being the only tool to meet acceptable thresholds across all assessed reliability measures. RELEVANCE TO CLINICAL PRACTICE: PI assessment in ICU patients should integrate validated tools with clinical judgement to address patient-specific and device-related risk factors.
Nursing in critical careRichard Kahalu, Joy Notter, Chris Carter
BACKGROUND: Critical care is an essential component of universal health care; however, its provision in low- and middle-income countries remains poorly understood. Although Zambia has expanded critical care services over the last 15 years, national evidence regarding workforce capacity, infrastructure and service provision remains limited. AIMS: To evaluate critical care workforce, service provision and patient case mix across Ministry of Health hospitals in Zambia. STUDY DESIGN: A cross-sectional survey was administered across 14 public hospitals with critical care units across Zambia, representing all 10 provinces. Data were collected via an e-survey questionnaire instrument. Descriptive statistical analysis was conducted using SPSS. Ethics approval was obtained prior to the study. RESULTS: All hospitals responded (n = 14/14, 100% response rate), accounting for a capacity of 131 critical care beds. Only 28.6% of hospitals had 24-h intensivist coverage, whereas all had registered critical care nurses. Equipment availability varied, with universal access to ventilators and monitors but limited access to syringe pumps and inconsistent availability of functional CT scanners. Over a 7-day period, 121 admissions were recorded, predominantly medical (29%), surgical (24.8%) and trauma-related (19.8%). Paediatric cases accounted for 40% of admissions. Formal admission and discharge protocols were present in fewer than half of the hospitals. CONCLUSION: The study provides the first national overview of public critical care provision in Zambia and provides a snapshot of current provision. The findings highlight urgent areas for capacity strengthening. RELEVANCE TO CLINICAL PRACTICE: Findings are similar to other studies within the sub-Saharan region and highlight the need to strengthen workforce training, particularly in critical and paediatric care, improve access to essential equipment and standardise care protocols to enhance patient safety and outcomes. The study demonstrates the importance of strengthening the multidisciplinary critical care workforce.
Acta anaesthesiologica ScandinavicaElisa Zoe Battistelli, Benjamin Skov Kaas-Hansen, Anders Granholm, Ronni Thermann Reitz Plovsing, Bodil Steen Rasmussen, Anders Perner, Maj-Brit Nørregaard Kjær
BACKGROUND: Patient-important outcomes beyond mortality, particularly health-related quality of life (HRQoL), are frequently used in intensive care unit (ICU) trials. However, HRQoL assessment remains challenging due to methodological complexities, including poorly defined recovery trajectories, lack of consensus on measurement instruments, complexity of statistical analysis, and missing data. Electronic patient-reported outcomes (ePROs) may improve data collection and efficiency, though their feasibility in ICU survivors is uncertain. METHODS: This protocol outlines a longitudinal, multicentre pilot study-within-a-trial aimed at evaluating the feasibility of ePRO-based HRQoL follow-up and exploring a trajectory-based approach to HRQoL characterisation after critical illness. We plan to enrol 100 participants already undergoing 180-day HRQoL follow-up in the Intensive Care Platform Trial (INCEPT) to complete monthly EQ-5D-5L surveys delivered by text messages from 6 to 12 months after randomisation. Feasibility outcomes include enrolment and response rate, time to completion, reminder-dependency, attrition pattern, agreement between modes of collection, and accessibility. Agreement between telephone- and ePRO-based assessments at 180 days will be evaluated at the group and at the individual level. Longitudinal EQ-5D-5L index values and visual analogue scale trajectories will be analysed using area-under-the-curve methods based on linear interpolation. Scenario-based sensitivity analyses will assess the potential impact of unobserved mortality among dropouts. DISCUSSION: We hypothesise that ePRO-based repeated assessments of HRQoL will support the goal of optimised data collection methods, while ensuring resources control. Moreover, identification of a candidate approach to HRQoL characterisation may shed light into the full recovery trajectory of ICU survivors and improve the interpretation and clinical relevance of HRQoL outcome assessments.
Nursing in critical careMarie O Collet, Camilla R L Bruun, Anders Granholm, Eva Laerkner, Anne C Brøchner, Annette L B Sørensen, Lone M Poulsen, Bodil S Rasmussen, Thomas Strøm, Anne-…
BACKGROUND: Patient and public involvement (PPI) is increasingly recommended in health research to enhance relevance, quality and implementation of findings. In intensive care research, involving patients, family members and healthcare professionals may help ensure that research addresses outcomes that are meaningful to those affected by critical illness. AIM: This study aimed to assess the level of meaningful PPI engagement during the development of a core outcome set (COS) for general intensive care unit (ICU) patients in Denmark. STUDY DESIGN: A cross-sectional survey using the Danish version of the Patient Engagement in Research Scale (PEIRS-22) was conducted between December 2024 and January 2025. We invited all members (patients, family, healthcare professionals and researchers) of five research panels, established in 2021 to support COS development across Danish university hospitals (N = 46). PEIRS-22 total scores range from 1 to 100, with higher scores indicating greater meaningful engagement (scores ≥ 70.1 were considered meaningful). Descriptive statistics, item-level analyses and non-parametric comparisons between participant roles were performed. RESULTS: Thirty-seven of 46 participants responded (80.4%): 27.0% (n = 10) were patients/family, 46.0% (n = 17) healthcare professionals and 27.0% (n = 10) researchers. The median PEIRS-22 total score was 78 (IQR 68-93), with 72.0% (n = 27) scoring ≥ 70.1. Engagement differed statistically significant by role (p = 0.004), with researchers reporting the highest scores (median 97), followed by patients/family (89), while healthcare professionals reported lower scores (74). CONCLUSION: PPI in COS development for general ICU patients was perceived as meaningful overall. However, differences across stakeholder groups and lower achievement of advanced engagement elements suggest opportunities to strengthen shared decision-making, role clarity and perceived relevance, particularly among healthcare professionals. Meaningful involvement of patients, families and clinicians may support the development of more patient-centred intensive care research and outcomes that better reflect the priorities of those affected by critical illness. RELEVANCE TO CLINICAL PRACTICE: Meaningful PPI can help ensure that intensive care research reflects the priorities of patients and families. Clear roles, clinical relevance, and opportunities to influence decisions may strengthen engagement, particularly among healthcare professionals. Critical care nurses may play an important role in facilitating collaboration between patients, families, clinicians, and researchers.
Nursing in critical careFritz Sterr, Lydia Bauernfeind, Anja Kepplinger, Christian Rester, Rebecca Palm, Sabine Metzing
BACKGROUND: Weaning from mechanical ventilation appears to be a complex intervention as defined by the Medical Research Council Framework. However, there is a lack of theoretical insights into ventilator weaning, and the underlying causal mechanisms have not yet been uncovered sufficiently. To understand its complexity in theory and develop it in practice, a program theory is currently being developed in a multi-method study. AIM: To identify key characteristics and mechanisms in ventilator weaning of adult intensive care patients. STUDY DESIGN: In this sub-study, we conducted semi-structured group discussions and workshops with 29 healthcare professionals in intensive care over 3 days in 2025 in Germany, using a qualitative design. The data were collected using audio recordings, field notes and photographs. After transcription, a deductive-inductive thematic analysis was performed. FINDINGS: The analysis revealed four principal themes: (1) complexity of ventilator weaning, (2) outcomes, (3) interventions and (4) links and relationships. The first theme combines factors such as definition and delimitation, dynamics, structure and individualization, which together describe the inherent complexity. The second theme covers different endpoints during the process, including preconditions and postconditions as well as intermediate, immediate and ultimate outcomes. The third theme comprises direct and indirect interventions, as well as nonprogram external factors. The fourth theme explores the connections between interventions, outcomes and contextual factors. CONCLUSION: The findings of this study support the understanding that ventilator weaning is a complex intervention. The identified interaction of the various interventions, outcomes and contextual factors needs to be theoretically organized and evaluated in future studies. RELEVANCE TO CLINICAL PRACTICE: Identifying the interactions between key characteristics in this process can improve HCPs' sensitivity to the effects of their own actions. A theoretical understanding of the mechanisms underlying ventilator weaning enables the targeted development and evaluation of a complex weaning intervention. TRIAL REGISTRATION: Open Science Framework YGJ3T; https://doi.org/10.17605/OSF.IO/YGJ3T, registered on 14 May 2025.
Acta anaesthesiologica ScandinavicaBenedikte Liebetrau, Andreas Ruhvald Madsen, Sören Möller, Markus Harboe Olsen, Sebastian Wiberg, Simon Mølstrøm
BACKGROUND: Intensive care unit (ICU) delirium is a multifactorial acute brain dysfunction associated with prolonged hospitalization, increased morbidity and mortality, and higher healthcare costs. Despite these substantial negative impacts of delirium, the optimal prevention and treatment strategies are unclear. Olanzapine, an atypical antipsychotic drug, is commonly used for delirium management. We will perform an updated systematic review and meta-analysis to assess the benefits and harms of olanzapine for the prevention and treatment of ICU delirium. METHODS: This protocol is developed in accordance with the recommendations of The Cochrane Collaboration and is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) guidelines. We will include all randomized clinical trials (RCTs) evaluating prophylactic or therapeutic olanzapine versus any comparator, including pharmacological, non-pharmacological, placebo, or routine care/no specific delirium-directed intervention (treated as a single comparator) in ICU patients. Observational studies will be included solely to address potential harms. We will systematically search the following databases: Embase, MEDLINE, The Cochrane Library, Web of Science, CINAHL, Scopus, and PsycINFO, as well as clinical trial registries. We will perform meta-analysis and trial sequential analysis (TSA) to investigate the risk of both Type I and II errors. We will assess the risk of bias using the Cochrane Risk of Bias tool (RoB-2). The quality of trials will be evaluated using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. The review is registered in the PROSPERO database (CRD420261474813). OUTCOMES: The primary outcome is days alive and out of the hospital. The secondary outcomes include all-cause mortality at 90 days, number of CAM-ICU (Confusion Assessment Method for the Intensive Care Unit) negative days at 30 days, number of days without pharmacological treatment for delirium other than study drug during the intervention period and serious intervention-related harms. DISCUSSION: This protocol outlines the methodology we will use in a systematic review with meta-analysis designed to evaluate the beneficial and harmful effects of olanzapine for prevention and treatment of delirium in ICU patients. The findings of the systematic review will be disseminated through peer-reviewed publication. We hope this review will inform future RCTs and improve clinical practice.
Nursing in critical careNana Wu, Xia Chen, Jie Fu, Liwen Ding, Hong Zhou, Tiantian Xiao
BACKGROUND: Point-of-care ultrasound (POCUS) is increasingly used in paediatric and neonatal critical care, but evidence on nurse-led bedside POCUS remains limited and fragmented. AIMS: This scoping review aimed to map the evidence on nurse-led bedside POCUS in paediatric and neonatal critical care nursing practice, examine implementation factors and identify evidence gaps relevant to nursing research, education and clinical practice. METHODS: Following JBI methodology and PRISMA-ScR guidance, we searched PubMed, Embase, CINAHL, Web of Science, Cochrane Library and CNKI from inception to October 2025. Eligibility followed the PCC framework. Two reviewers independently screened records and extracted data using a standardized form. Study characteristics were synthesized descriptively, and implementation factors were deductively analysed using the COM-B framework. RESULTS: Thirty-four studies were included, mainly from the United States and China. Nurse-led POCUS applications included vascular access, respiratory assessment, catheter localization, cardiac or hemodynamic evaluation, bladder assessment and education or competency development. Outcomes included clinical (procedural success and diagnostic accuracy), process (timeliness and workflow efficiency) and nurse-related (competency, confidence and role development). Safety-related outcomes were the least reported. Implementation was influenced by training, equipment, protected time, institutional support, collaboration and patient safety concerns. The automatic motivation domain, referring to unconscious drivers such as habits and emotional responses, was not addressed by any study. CONCLUSIONS: Nurse-led POCUS is an emerging but unevenly developed component of paediatric and neonatal critical care. Brief training may support initial competency, but sustained implementation is constrained by underdeveloped quality assurance, unclear career pathways and limited attention to motivational processes. RELEVANCE TO CLINICAL PRACTICE: Future nursing research and clinical programmes may look beyond short-term training outcomes to consider competency standards, longitudinal supervision, quality assurance, educational approaches combining foundational POCUS training with structured workplace supervision and sustainable integration into routine care delivery.
Nursing in critical careAyda Kebapcı, Begum Yalçın, Deniz Eşim, Gülşah Doğan, Şahika Mert
BACKGROUND: During the orientation process in the intensive care unit (ICU), the experiences and challenges of new nurses and their mentor nurses often differ, leading to potential incompatibilities. AIMS: This descriptive qualitative research aimed to determine the opinions and experiences of newly recruited nurses and their mentor nurses on the adaptation to the ICU. STUDY DESIGN: Semi-structured interviews were conducted with 21 nurses (10 mentors and 11 mentees) who worked in an ICU. Data were collected between March and May 2025. Four focus group interviews were conducted with mentors and mentees. Data were analysed using content analysis. Consolidated Criteria for Reporting Qualitative (COREQ) was used for reporting. FINDINGS: In the mentor group, three themes emerged: (1) mentor challenges in mentee conflicts, (2) helpful or harmful: a mentor's dilemma and (3) double duty: the rising workload of nurse mentors; in the mentees group, two themes emerged: (1) mentee challenges in mentor conflictsand (2) a good system with operational gaps. CONCLUSIONS: The study reveals the complex challenges faced by both new nurses and their mentors in the ICU. Although mentorship supports professional growth and patient safety, issues such as poor communication, mismatched expectations and emotional strain can hinder its effectiveness. These findings highlight the need to view mentorship as both an educational and an emotional process that requires mutual support. RELEVANCE TO CLINICAL PRACTICE: The study demonstrates that ICU mentorship must be recognized as a high-intensity clinical responsibility, requiring dedicated time to prevent mentor burnout and ensure patient safety. By addressing the identified communication gaps and 'double duty' burdens, healthcare managers can create a more resilient orientation system that improves the retention of newly recruited nurses.
Acta anaesthesiologica ScandinavicaEmma Larsson, Arman Valadkhani, Jesper Eriksson, Erik Svensk, Fredrik Hammarskjöld, Markus Castegren, Peter Bentzer, Nicklas Nielsen, Kristina Svennerholm, Mik…
BACKGROUND: Healthcare overuse, including unnecessary diagnostic testing and procedures, contributes to patient harm, increased healthcare costs, and resource waste. The Choosing Wisely initiative aims to reduce low-value care through evidence-based recommendations. However, limited evidence exists regarding the safety and effectiveness of implementing Choosing Wisely recommendations in intensive care settings. METHODS: The WICH-ICU is a registry-based stepped-wedge cluster randomized controlled trial designed to evaluate the implementation of specific Choosing Wisely interventions in Swedish intensive care units (ICUs). The study will include adult patients treated in participating Swedish ICUs. The intervention consists of three parts of the Choosing Wisely recommendations: (1) reduced frequency of arterial blood gas sampling, (2) reduced routine laboratory testing, and (3) reduced routine chest radiography. The primary outcome is 30-day mortality. Secondary outcomes include ICU length of stay, duration of mechanical ventilation (invasive and noninvasive), continuous renal replacement therapy duration, and ICU readmission within 72 h. Intervention data, testing intensity (arterial blood gas samples, laboratory tests, and chest radiographs per patient-day), will be collected through local monitoring, while outcome data will be obtained from the Swedish Intensive Care Registry (SIR). The stepped-wedge design allows each participating ICU to serve as its own control, with randomized timing of intervention implementation. DISCUSSION: This study will provide evidence on the safety and effectiveness of implementing Choosing Wisely recommendations in intensive care settings. The stepped-wedge cluster randomized design minimizes contamination while allowing all participating sites to eventually receive the intervention. The results will inform evidence-based de-implementation strategies in critical care. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT07013175.
JMIR human factorsSarah Frederika Christina Mugge, Tobias Daniel van Leijsen, Merijn Constantijn Reuland, Annelies Visser, Frederique Paulus, Dave Anton Dongelmans
BACKGROUND: Lung-protective ventilation (LPV) reduces complications of mechanical ventilation, yet adherence in intensive care units (ICUs) remains inconsistent. Digital dashboards may support LPV by improving situational awareness and supporting protocol adherence. However, adoption of such tools in high-acuity clinical environments depends on a range of cognitive, professional, and contextual determinants. The Measurement Instrument for Determinants of Innovations (MIDI) provides a validated framework to systematically assess these factors. OBJECTIVE: This study aims to identify determinants influencing the adoption of a newly piloted mechanical ventilation dashboard in the ICU using the MIDI framework. METHODS: We conducted a single-center, cross-sectional evaluation among ICU health care professionals during a dedicated survey period within a pilot introduction of a mechanical ventilation dashboard at Amsterdam University Medical Center. Participants completed a structured questionnaire consisting of 24 MIDI items adapted to the ICU context rated on a 5-point Likert scale ("completely disagree" to "completely agree"), supplemented by open-ended questions on perceived barriers and facilitators to its use. Determinants were classified as facilitators when ≥80% of respondents selected "agree" or "completely agree" and as barriers when ≥20% selected "disagree" or "completely disagree." Open-ended responses were analyzed using a general inductive thematic approach. RESULTS: A total of 71 completed questionnaires were analyzed, including responses from nurses, physicians, intensivists, ventilation specialists, and researchers in mechanical ventilation. Six determinants met the criteria for facilitators: outcome expectations, self-efficacy, procedural clarity, low complexity, correctness, and observability. Two determinants met the criteria for barriers: relevance for client and professional obligation. Analysis of open-ended responses highlighted perceived barriers such as additional workload, the need for an extra device, overlap with existing systems, and limited role-specific relevance. Facilitators included improved situational overview, educational value, easier trend monitoring, and increased efficiency. CONCLUSIONS: This evaluation identified key determinants influencing the adoption of a mechanical ventilation dashboard in the ICU. While the dashboard was generally perceived as useful and easy to understand, adoption was shaped by determinants related to workflow integration, role-specific relevance, and professional responsibility. These findings suggest that successful introduction of digital clinical support tools in intensive care requires attention not only to technical design, but also to how such tools align with users' roles, daily work processes, and shared clinical responsibilities. Systematic assessment of determinants provides actionable insights into the adoption of digital decision-support tools in high-acuity care settings.
European journal of psychotraumatologyShamini Satkunam, Irene Dimitriou, Madiha Shaikh
Background: Psychological morbidity is common following admission to adult intensive care units (ICUs), with many patients experiencing post-traumatic stress disorder (PTSD), anxiety, and depression as part of post-intensive care syndrome. Eye Movement Desensitisation and Reprocessing (EMDR) is an established trauma-focused psychological therapy; however, its evidence base within critical care populations remains emerging.Objectives: This scoping review aimed to map the extent, characteristics, and findings of the available literature on the use of EMDR for ICU-related psychological distress.Methods: A scoping review was conducted in accordance with Joanna Briggs Institute methodology and reported following the PRISMA-ScR guidelines. The review aimed to systematically identify and synthesise evidence relating to the application and reported outcomes of EMDR in ICU survivors.Results: Seven publications representing six independent study populations were included. Participants included adult ICU patients experiencing PTSD symptoms, delirium-related psychological disturbances, and COVID-19-related distress. EMDR was delivered using either standard protocols or the Recent Traumatic Episode Protocol (R-TEP). Across the evidence base, EMDR was associated with reductions in trauma-related distress, although evidence for improvements in anxiety and depression was less consistent. Where qualitative data were available, participants additionally reported improved integration and processing of ICU experiences. Overall, methodological heterogeneity, overlapping samples, small sample sizes, and limited controlled evidence restrict the strength of conclusions that can be drawn.Conclusions: This review highlights growing but preliminary evidence supporting the feasibility and potential utility of EMDR, including R-TEP, for ICU-related psychological distress. While findings are promising, the current evidence base remains insufficient to determine effectiveness. Future research should prioritise adequately powered controlled studies, standardised outcome measures, longer-term follow-up, and more diverse ICU populations to strengthen the evidence base and inform clinical implementation.
JMIR human factorsMeghana Darla, Danielle Miltz, Khushboo Chandnani, Saptarshi Purkayastha, John W Diehl, Sivasubramanium V Bhavani
BACKGROUND: AI has the potential to enhance clinical decision-making in high-acuity settings such as intensive care units (ICUs) and emergency departments (EDs). However, despite promising performance, many AI-driven clinical decision support systems (AI-CDSSs) face poor adoption due to issues of trust, workflow disruption, and alert fatigue. Understanding the human factors that shape clinician acceptance is critical to guide safe and effective implementation of AI-CDSS in acute care. Theoretical frameworks, including the Systems Engineering Initiative for Patient Safety (SEIPS) 2.0 model and the technology acceptance model (TAM), suggest that successful adoption requires addressing sociotechnical interactions among clinician trust, system design, organizational readiness, and task complexity, yet few empirical studies have applied these frameworks to AI-CDSSs in acute care settings. OBJECTIVE: This study aimed to evaluate emergency medicine and critical care clinicians' perceptions of AI-CDSSs and to identify key factors influencing adoption, including trust, design preferences, and workflow integration. METHODS: A SEIPS 2.0-informed mixed methods study evaluated ICU and ED clinicians from Emory Healthcare on perceptions of AI in clinical practice. An expert-reviewed survey (N=57) assessed clinician perceptions, trust, and implementation preferences. Semistructured interviews (n=11) included A/B testing of AI-CDSSs and clinical sepsis scenarios to explore decision-making in context. Transcripts were thematically analyzed using the Braun and Clarke framework in ATLAS.ti (version 26, ATLAS.ti Scientific Software Development). Quantitative data were analyzed descriptively. This study assessed clinician perceptions using mock alerts and hypothetical scenarios rather than real-world AI-CDSS deployment. RESULTS: Trust in AI varied significantly by patient acuity (Cochran Q=30.40, P<.001): stable patients (43/57, 75%, 95% CI 63%-85%), deteriorating patients (27/57, 47%, 95% CI 35%-60%), and critically ill patients in the ICU and undifferentiated patients in the ED (25/57, 44%, 95% CI 32%-57% for each scenario). Internal consistency was acceptable-to-good across three scales (Cronbach α: AI Perception=.891, Trust=.743, Implementation=.740; McDonald ω: AI Perception=0.895, Trust=0.782, Implementation=0.746). Barriers included overreliance, insufficient training, and data quality concerns. For the exploratory AI-CDSS design, clinicians preferred opt-in alerts (10/11, 91%), evidence-linked recommendations (7/11, 64%), and avoiding overt mention of increased AI acceptance (8/11, 73%). Thematic analysis yielded 36 themes across six domains: trust and transparency, alert usability, workflow fit, data concerns, training needs, and perceived clinical impact. Clinicians favored AI-CDSSs that preserved autonomy, minimized disruption, and provided transparent rationales. CONCLUSIONS: Adoption of AI-CDSSs in critical care is not solely a technical issue but a human-factors challenge centered on trust, transparency, and workflow compatibility. These findings support future testing of a phased implementation approach-beginning with lower-acuity applications where clinician trust is highest, then gradually extending to higher-acuity scenarios with enhanced transparency and override mechanisms. This graduated strategy addresses the critical interdependencies among people (trust), tools (design), organizations (training), and tasks (clinical complexity) identified in this study.
Giornale italiano di cardiologia (2006)Simona Giubilato, Francesca Musella, Carlotta Sorini Dini, Francesco Piroli, Nicola Gasparetto, Serena Guasti, Roberta Della Bona, Daniela Zabbia, Francesca Ca…
Point-of-care ultrasound (POCUS) is an imaging modality performed and interpreted by the treating physician at the bedside, with immediate integration of findings into clinical decision-making. Its rapid expansion in emergency medicine, critical care, and resource-limited settings has significantly improved diagnostic and therapeutic timeliness. However, this growth has highlighted the need to clearly define its scope of practice, standardize protocols, and distinguish POCUS from comprehensive consultative echocardiography. This review outlines the historical evolution of POCUS, from early trauma applications to structured protocols for shock, dyspnea, and cardiac arrest, and its current role in cardiopulmonary and hemodynamic monitoring of critically ill patients. Recent international guidelines are summarized, emphasizing POCUS as a distinct and complementary clinical tool rather than a replacement for formal imaging. Finally, future perspectives involving artificial intelligence and robotic ultrasound technologies are discussed, addressing their potential benefits and associated educational, organizational, and ethical challenges.
INTRODUCTION: In the past decade, the use of antidepressants in Iceland has increased rapidly. Given their widespread use, it is important to assess potential effects of SSRI/SNRI exposure during pregnancy on the newborn. The aim of this study was to examine the prevalence of SSRI/SNRI use at the time of delivery, the frequency of neonatal support or resuscitation, monitoring or admissions to the neonatal intensive care unit (NICU), and which clinical signs may possibly be linked to SSRI/SNRI exposure during pregnancy. METHODS: This was a retrospective comparative study, including all infants born at Landspítali in 2023 (n=3200). Infants born before 35 weeks of gestation were excluded. The study group consisted of infants whose mothers were on SSRI/SNRI treatment upon delivery, while the control group included all other infants in the study population. Additionally, infants admitted to the NICU were examined in more detail. RESULTS: Out of 3069 infants, 336 (10.9%) were exposed to SSRI/SNRI treatment during pregnancy. The need for neonatal support was significantly higher in the SSRI/SNRI group (29.2%) compared with controls (14.6%). Similarly, NICU admission or monitoring was more common (19.4% vs. 13%). Other significant differences included higher rates of respiratory distress, lower Apgar scores at 1 and 5 minutes, and more frequent sepsis work-ups in the SSRI/SNRI group. CONCLUSIONS: Infants exposed to maternal SSRI/SNRI treatment are more likely to require postnatal support, including oxygen therapy and respiratory assistance, as well as NICU care. Furthermore, these infants have lower Apgar scores at birth, and increased rate of sepsis work-up.
Nursing philosophy : an international journal for healthcare professionalsStelios Parissopoulos, Fiona Timmins, Marianna Mantzorou, George Tsakonitis, Meropi Mpouzika, Eleni Papagaroufali
This paper presents a focused analysis arising from a broader ethnographic study of nursing praxis, power relations, and clinical decision-making in a Greek ICU. The aim of this paper is to explore the morning bed-bath as a culturally embedded ICU nursing practice and to interpret how bodily care, professional identity, organisational routines and relational attentiveness intersect within this everyday activity. Informed by critical medical anthropology and phenomenology, the study draws on participant observation, ethnographic fieldnotes, and interviews with intensive care staff. The interpretation draws primarily on Foucault's concept of discipline, complemented by Bourdieu's notion of habitus and embodied practice, and Douglas's work on purity and symbolic order. Three interrelated themes emerged, forming a 'triptych of care': a) proximity and synchronicity to the patients' needs and clinical condition, which revealed skilled bodily attentiveness, clinical judgement and nursing agency, alongside negotiations of professional knowledge, and authority; b) the creation of a zone of safety and privacy, where bodily exposure, dignity, relational care, and professional interaction were negotiated within the ICU environment; and c) the removal of dirt and impurities, which served immediate clinical and hygienic purposes while also carrying cultural and professional meanings associated with bodily presentation, cleanliness, and order. The findings suggest that the morning bed-bath in the ICU studied was not merely a technical nursing task, but a culturally embedded and routinised practice through which temporal and organisational routines, embodied care, symbolic order, and professional nursing values are enacted.
Acta anaesthesiologica ScandinavicaAleksandra E Wlodarczyk-Abou Elseoud, Maija-Liisa Kalliomäki, Otto Mäkinen, Annika Laukkanen, Minna Bäcklund, Mitja Lääperi, Katri Hamunen, Anna-Maria Kuivalai…
BACKGROUND: A considerable proportion of patients in the intensive care unit (ICU) experience pain. The objective of this prospective observational cohort study was to investigate the prevalence of pain, factors associated with pain and pain trajectories in ICU patients. METHODS: Critically ill adult patients admitted to four ICUs across two tertiary university hospitals between 2018 and 2020 were recruited. Patients were followed during ICU stay for up to 14 days. Pain was measured using the Numeric Rating Scale (NRS), the Critical Care Pain Observation Tool (CPOT) and the Verbal Rating Scale (VRS). The primary outcome was the prevalence of at least moderate pain at rest defined as NRS ≥ 4, VRS ≥ moderate pain or CPOT ≥ 3. Risk factors for pain were analyzed with mixed effects logistic regression models. To enable a visual analysis of pain prevalence, a trajectory model was constructed based on pain assessment data. RESULTS: In total, 711 patients participated in the study. Most patients (76.4%) had at least moderate pain at some point during their ICU stay. Female sex, surgical reason for admission and opioids administered during ICU stay were all associated with increased odds for pain, whereas continuous sedation and a higher SAPS II score decreased the odds. The prevalence of at least moderate pain did not decline during ICU stay. CONCLUSION: The prevalence of at least moderate pain is relatively high in critically ill patients despite frequent use of opioids in the ICU. Identifying patients at risk for pain may aid in individualising pain management. EDITORIAL COMMENT: In this prospective study in a mixed adult ICU cohort, pain prevalence, character and trajectory is described. The majority of cases reported pain at rest, and case factors are presented.
Critical care nurseWei Jun Dan Ong, Eleanor Dela Peña, Faheem A Khan, Woon Hean Keenan Chong, Lawrence Ace Azul
BACKGROUND: Noninvasive ventilation is increasingly delivered outside intensive care units; however, ventilator alarm management, documentation, and competency validation remain inconsistent when paper-based processes are used. Delayed or inconsistent responses to actionable alarms may contribute to clinical deterioration and escalation of care. LOCAL PROBLEM: Nurses and respiratory therapists reported fragmented documentation, limited access to standardized troubleshooting guides, and time-consuming competency tracking for noninvasive ventilation devices in acute medical units that provide intermediate-level care. METHODS: This quality improvement project, which used a pre-post design, involved implementation of a digital ventilator safety workflow using QR code-linked alarm guidance and a secure online checklist. Data were collected during a 6-month baseline period and a 6-month postimplementation period. Clinical content, workflow mapping, and alarm-guidance pathways were developed in-house by the respiratory therapy department and deployed through AskVijay, a digital clinical guidance platform. Competency validation was conducted during onboarding and annual assessment. RESULTS: Digital implementation was associated with an increase in checklist completion compliance from 80% to 100% and a reduction in checklist completion time from a median of 8.5 minutes to 3.9 minutes. Use of required digital fields supported more complete documentation. Centralized electronic records enabled consolidated competency documentation and facilitated tracking of checklist and competency completion. CONCLUSION: A digital ventilator safety workflow supported standardized documentation, point-of-care access to alarm guidance, and competency tracking for unit-based noninvasive ventilation care. In-house clinical development enabled iterative refinement to align with local practice needs and workflows.
Journal of evaluation in clinical practiceRitika Panekar, Manish Prannath Shukla, Santosh P Dobhal
BACKGROUND: Translating evidence-informed recommendations into routine critical-care physiotherapy remains challenging because clinical decision-making occurs within dynamic and context-dependent environments. The mindlines model provides a conceptual perspective for understanding how clinicians integrate research evidence with experiential, social, and contextual knowledge during everyday practice. However, its application in critical-care physiotherapy remains poorly understood. OBJECTIVE: To explore how physiotherapists working in critical-care units develop and apply mindlines during clinical decision-making and how evidence-informed recommendations are integrated into routine practice. METHODS: A qualitative exploratory study was conducted using semi-structured interviews with 22 experienced physiotherapists from diverse critical-care settings. Participants had 5-20 years of ICU experience and were recruited through purposive sampling. Data were analysed using reflexive thematic analysis following an inductive approach, with interpretation informed by the mindlines model. Reporting adhered to the COREQ. 32-item checklist. RESULTS: Five interconnected themes were identified: (1) experience as the primary driver of clinical reasoning, (2) interdisciplinary collaboration shaping decision-making, (3) contextual adaptation of evidence-informed recommendations, (4) time constraints influencing engagement with formal evidence and (5) organisational variation across institutional settings. Participants described integrating research evidence with accumulated clinical experience, multidisciplinary interactions, and contextual factors to support patient-specific decision-making in complex critical-care environments. CONCLUSION: Clinical decision-making in critical-care physiotherapy reflects the integration of evidence-informed recommendations with experiential, collaborative, and contextual knowledge through clinicians' mindlines. Recognising these knowledge-translation processes may inform educational, implementation, and organisational strategies that strengthen evidence-informed physiotherapy practice in critical-care settings.
Critical care explorationsSue Brierley-Hobson, Ashley DePriest
Morowitz et al argue that the composition of enteral nutrition formulas deserves to be studied as an intervention in its own right. Building on this perspective, we consider how critical care nutrition research has progressively refined its questions from whether to feed to when and how much. We argue that enteral formula composition represents the next logical frontier in critical care nutrition research, while emphasizing the need for biologically informed, clinically meaningful, and practical interventions. We also highlight the importance of learning from previous translational challenges to ensure that future research identifies formulations that improve patient outcomes while remaining feasible for routine critical care practice.
European journal of neurologyClément Caiazzo, Estelle Pruvost-Robieux, Ghazi Hmeydia, Eleonore Bouchereau, Camille Legouy, Charlotte Calligaris, Julie Lévi-Strauss, Catherine Oppenheim, Sa…
BACKGROUND: Management of lasting disorders of consciousness (DoC) is complex and sometimes requires referral of patients to an expert team. We aimed to evaluate the impact of such specialized expert assessment through the description of a single-center experience. METHOD: Monocentric study including all patients with DoC referred to a tertiary neuroICU for multimodal clinical, electrophysiological, and MRI assessment allowing diagnostic and therapeutic proposals and multidisciplinary prognostic prediction. The primary endpoint was the patients' actual outcome, assessed by 3-month functional disability and 1-year mortality, according to the predicted prognosis. RESULTS: Between July 2017 to June 2024, 124 patients (median age 61 [49-70] years, 67% of men) were referred from 43 departments of 37 primary hospitals. Most frequent etiologies were post-anoxic encephalopathy (62%) and secondary systemic brain injuries (15%). At a median of 23 [15-33] days after DoC onset, predicted prognosis was good in 20 (16%) patients, intermediate in 41 (33%), and poor in 63 (51%). Three-month GOS-E was 3 [1-3], 2 [1-3], and 1 [1] (p < 0.001) and 1-year mortality was 30%, 41%, and 82% (p < 0.001), respectively. Withdrawal of life-sustaining therapies increased with worsening predicted prognosis (38%, 41%, and 65%, respectively, p < 0.001), but functional disability and mortality remained higher in the poor prognosis group (p < 0.003 and p < 0.039, respectively) even after excluding patients with those decisions. CONCLUSION: Specialized consciousness assessment impacts the ethical decisions made by primary centers and helps refine the prediction of recovery but fails to achieve highly accurate individual prediction in a population with overall poor survival and functional prognosis.
Ulusal travma ve acil cerrahi dergisi = Turkish journal of trauma & emergency surgery : TJTESZehra Hatipoğlu, Ömer Doğan, Mehmet Gökhan Gök, Kaniye Aydın, Ersel Güleç, Mediha Türktan, Ferhat Çetinkaya, Eda Macit Aydın, Büşra Tezcan, Murat Sayın, Ahu Du…
BACKGROUND: Crush syndrome (CS) is a clinical condition associated with multisystem organ dysfunction that develops after traumatic rhabdomyolysis and primarily affects the kidneys. The aim of this study was to characterize the incidence, risk factors, and treatment patterns of acute kidney injury (AKI) in earthquake victims with CS, with a particular focus on renal replacement therapy (RRT) use and clinical outcomes. METHODS: In this retrospective multicenter study, 247 adult patients with earthquake-related CS who were admitted to intensive care units (ICUs) in 22 hospitals after the Kahramanmaraş 2023 earthquakes were analyzed. Demographic data, injury patterns, laboratory parameters, treatment protocols, and outcomes were evaluated during the first 15 days following ICU admission. RESULTS: AKI developed in 78.5% (n=194) of patients, and RRT was required in 62.4% (n=121) of those with AKI. Multiple logistic regression analysis demonstrated that myoglobin and creatinine levels were associated with an elevated risk of developing AKI (odds ratio [OR]: 1.001; 95% confidence interval CI: 1.000-1.001 and OR: 1.735; 95% CI: 1.151-2.615, respectively). Similarly, creatinine level and reasons for ICU admission were identified as factors influencing RRT administration. (OR: 1.7; 95% CI: 1.28-2.15 and OR: 2.9; 95% CI: 1.26-6.90, respectively). The 30-day mortality rate was higher in patients with AKI than in those without AKI. Mortality rates were similar between patients with AKI who received RRT and those who did not. CONCLUSION: This study demonstrates the high incidence of AKI in earthquake-related CS, underscores the need for improved disaster preparedness with adequate dialysis capacity and early risk stratification using serum myoglobin and creatinine levels for optimal management.
Physiotherapy research international : the journal for researchers and clinicians in physical therapyPedro Vinicius Porfirio, Wagner Souza Leite, Layane Santana Pereira Costa, Pedro Henrique de Moura, Ana Célia Oliveira Dos Santos, Emanuel Fernandes Ferreira d…
OBJECTIVE: To map and synthesize methodological approaches used for ultrasound (US) assessment of peripheral (upper- and lower-limb) and abdominal muscle thickness in critically ill patients, and to propose a preliminary Standard Operating Procedure (SOP) as a structured reporting framework. METHODS: A review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews checklist, using systematic searches on PubMed, BIREME (including MEDLINE, LILACS and IBECS) and Embase. Two reviewers independently screened, selected, and extracted data from studies published between 2015 and 2025. Extracted data included muscle groups assessed, thickness measurement criteria, patient and probe positioning, operational US parameters, and reliability information. The proposed SOP was developed based on recurring methodological patterns identified in the literature and subsequently refined through external expert review and pilot feasibility testing in ICU settings. RESULTS: Of 2.293 identified records, 29 studies (1.736 patients) were included. B-mode imaging and linear transducers were the most frequently reported US parameters, and the supine position with the head of the bed elevated to 30° was the predominant patient position. Although 79.3% of studies described muscle thickness measurement criteria, important methodological details such as depth, gain, and anatomical landmarks were inconsistently reported. Lower-limb muscles were the most frequently assessed, whereas upper-limb and abdominal muscles remained comparatively underrepresented. Considerable variability was identified across acquisition procedures, anatomical landmarks, measurement criteria, and reporting practices. CONCLUSIONS: Ultrasound assessment of muscle thickness in critically ill patients shows substantial methodological and reporting variability. A preliminary SOP was developed and pilot-tested to improve consistency and comparability. Standardization may support bedside monitoring and inform physiotherapy assessment and rehabilitation decisions, although multicenter validation is required. TRIAL REGISTRATION: Open Science Framework: https://doi.org/10.17605/OSF.IO/S95MJ.
Pediatric annalsJennifer L Fang, Mark W Kaczor, Whitney S Thompson, Christopher A Collura
Telemedicine, rapid genomic sequencing (rGS), artificial intelligence (AI), and emerging interventions at the limits of viability are reshaping neonatal critical care and transforming the future of neonatology. Telemedicine is expanding neonatal expertise beyond tertiary centers, improving access and continuity of care through prenatal consultation, tele-resuscitation, virtual rounds, and home monitoring. Advances in rGS are shifting neonatal diagnostics toward earlier, precision-based identification of genetic disease, enabling more individualized treatment and prognostication. AI applications in the neonatal intensive care unit are demonstrating promise in early disease detection, imaging interpretation, predictive analytics, and clinical decision support, with the potential to improve outcomes while reducing clinical burdens. Neonatology continues to consider ethical challenges at the limits of viability. The potential for artificial womb technology raises complex questions regarding fetal status, viability thresholds, and the future implications of ectogenesis prompting the urgent need for evolving ethical frameworks.
Pediatrics in reviewChetna K Pande, Sarah Risen, Jessica M LaRosa, Sapna R Kudchadkar
As mortality from pediatric critical illness has declined, post intensive care syndrome in pediatrics (PICS-p) has emerged as a framework to describe the broad and often long-lasting morbidities experienced by survivors of pediatric critical illness. PICS-p encompasses new or worsening impairment in physical, cognitive, emotional, and social health that affect both the child and their family. The term PICS-p also acknowledges and reinforces the traumatic impact of the critical care on the child and family dyad. Given the growing population of pediatric survivors of critical illness and the limited availability of newly emerging, specialized post-critical care clinics, it is imperative that general pediatricians, providing the child's medical home, are equipped to diagnose and manage PICS-p in the outpatient setting. In this review, we summarize the prevalence, pathophysiology, clinical course, and impact of PICS-p on children and families. We also review preventive strategies that can be implemented in the PICU and conclude with practical guidance for general pediatricians caring for children after critical illness.
Nursing philosophy : an international journal for healthcare professionalsZhuanlian Li, Jiaqi You, Liuhua Zhang, Bangxing Ma, Yinhua Liu
Pain assessment in critical care is organised primarily around patient self-report and numerical scoring, an arrangement that protects the patient's first-person authority. In neurocritical care, however, critically ill patients with stroke may be unable to communicate because of aphasia, impaired consciousness, sedation, mechanical ventilation, or delirium. Under these conditions, the absence of a numerical score may reflect limitations in the systems through which pain is made visible rather than the absence of pain. This paper offers an empirically informed philosophical analysis of what a missing numerical pain score means in neurocritical care and asks how nursing can preserve clinically and ethically meaningful distinctions when a number cannot be responsibly produced. As an empirical point of departure, an extracted adult ischaemic-stroke ICU-stay dataset from MIMIC-IV (6054 ICU stays, 5065 patients) was used, focusing on the first pain score, defined as the earliest documented numerical pain score within the first 24 h after ICU admission among patients with stroke. The empirical material is treated not as epidemiological evidence but as an occasion for conceptual analysis. Of 6054 ICU stays, 2415 (39.9%) had no documented first pain score in the first-24-h structured field. This pattern is not interpreted as evidence that pain was absent, unassessed, or unrecognised in any individual case. Drawing on this finding, the paper develops a five-fold conceptual taxonomy of missingness: absence of pain, absence of self-report, absence of assessment, absence of documentation, and risk of non-recognition. Nursing management is presented as a moral-epistemic practice in which electronic record categories, quality indicators, staffing, education, and workflow shape whether possible pain becomes visible, documentable, auditable, and answerable. The central task is not to force every patient into a number, but to preserve clinically and ethically meaningful differences when a number cannot be responsibly produced.
Diving and hyperbaric medicineAlice Palmer, Craig Holdstock, Doug Watts, Rosanna J Stokes, Jack Whiteley
An experienced recreational diver developed a severe multisystem life-threatening decompression sickness following a series of eight dives over four days, the profiles of which were all within acceptable limits. The diver had marked haemoconcentration and required large volume intravenous fluid replacement during initial treatment. Similar presentations have previously only been described following deep dives, fast ascents or where mandatory decompression had been missed. The management of this case, including the involvement of a hyperbaric unit co-located to an intensive care department, and the underlying pathophysiology are discussed.
Disaster medicine and public health preparednessManuel Walter, Sarah Thiel, Helge Junge, Nils Thöni, Dominic Schier, Armin Hess, Paolo Rodi
BACKGROUND AND IMPORTANCE: In mass-casualty incidents, inaccurate pretriage labeling at Advanced Medical Post (AMP) arrival, whether due to undertriage or clinical deterioration before arrival, may affect downstream workflow processes and delay recognition of critically injured patients. Although triage accuracy has been widely studied, the operational impact of inaccurate pretriage labelling at AMP entry on time-critical care processes within AMP systems remains poorly understood. OBJECTIVE: To evaluate the impact of inaccurate pretriage labeling at AMP entry on downstream time-critical care processes in simulated red-category patients. DESIGN, SETTING, AND PARTICIPANTS: Prospective, pilot simulation-based study conducted during 2 full-scale AMP exercises. The AMP reflected the real-world operational structure, personnel, and logistics of an AMP deployed during the World Economic Forum (WEF) 2026. Each simulation included 18 standardized patients; 10 met predefined red-triage criteria and constituted the analytic cohort. The primary objective was to compare time to predefined first critical action between correctly labeled and mislabeled patients. EXPOSURE: Mislabeled at AMP entry, defined as red patients entering the AMP undertriaged with a lower-acuity pretriage label (yellow instead of red). OUTCOMES MEASURE AND ANALYSIS: The primary outcome was time from AMP entry to first predefined critical action. Secondary outcomes included reaching predefined case-specific deterioration or death thresholds prior to intervention and time to correction of triage category. Outcomes were analyzed descriptively using within-patient paired comparisons across simulation runs. MAIN RESULTS: Across 2 simulation runs, 6 paired observations were analyzed. In 4 of 5 comparisons in which a predefined critical action was performed, mislabeling was associated with longer time to predefined critical action, with delays ranging from 5 to 24 minutes. In 2 cases, these delays resulted in crossing of case-specific deterioration thresholds. In 1 additional mislabeled patient, the predefined critical action was not performed before the deterioration threshold was reached, and the patient subsequently progressed to the scripted death threshold. No correctly labelled red patient reached deterioration or death. Early correction of triage status mitigated delays, whereas delayed correction was associated with adverse progression. CONCLUSION: In this pilot full-scale simulation study, inaccurate pretriage labeling at AMP entry was associated with delays in time-critical interventions. These findings highlight the importance of early and continuous structured reassessment and timely correction of triage categorization within AMP workflows. The results are hypothesis-generating and require confirmation in further simulation or real-world studies.
BACKGROUND: Delirium prevalence in the intensive care unit (ICU) is high. Intensive nursing interventions have been performed to reduce delirium in ICU patients. There is now a wide variety of intensive nursing interventions available for treating delirium. However, the optimal intervention remains unknown. This systematic review and network meta-analysis (NMA) aimed to compare the efficacy of intensive nursing interventions in patients with delirium. METHODS: We included randomized controlled trials of different intensive nursing interventions for delirium in the ICU. A Bayesian NMA was conducted to evaluate the efficacy of various types of intensive nursing interventions. The outcomes assessed were the cure rate, intensive care delirium screening checklist (ICDSC) scores, and acute physiologic assessment and chronic health evaluation II (APACHE II) scores for different treatments. RESULTS: This meta-analysis included 21 studies. We analyzed a total of 5 different intensive nursing interventions: auricular points acupressure, music therapy, cognitive function exercise, regular nursing, increasing visiting hours, and targeted nursing. When compared with regular nursing, the other 5 intensive nursing interventions showed no significant difference in cure rate, ICDSC, and APACHE II scores (P > .05). Auricular points acupressure had the highest surface under the cumulative ranking area value for cure rate and APACHE II, indicating it ranked first in these outcomes. Music therapy demonstrated the most favorable effect on reducing ICDSC, with music therapy ranking first in this regard. CONCLUSION: This NMA suggests that auricular points acupressure might be the optimal intervention for increasing the cure rate and decreasing ICDSC and APACHE II scores in ICU patients with delirium. However, the surface under the cumulative ranking area values reflect relative ranking rather than absolute efficacy, and no intervention demonstrated statistically significant superiority over regular nursing. Additionally, increasing visiting hours appears to hold promise as an effective intervention for reducing delirium in the ICU. Further research and larger studies are warranted to confirm these findings and to explore the long-term benefits of these intensive nursing interventions in delirium management.
Medical science monitor : international medical journal of experimental and clinical researchMichal Kalina, Ondřej Jíra, Vladimír Černý
BACKGROUND Twenty-four-hour fluid balance is routinely used as a surrogate marker of net fluid change in critically ill patients and frequently influences bedside clinical decision-making, including assessment of volume status and fluid management strategies. However, despite its widespread use in intensive care practice, the reliability and accuracy of this routinely recorded parameter as a measure of short-term fluid change remain uncertain. MATERIAL AND METHODS We conducted a prospective multicenter observational study comparing cumulative 24-hour fluid balance with 24-hour body weight change measured over identical time intervals in adult patients admitted to the intensive care unit (ICU). Paired measurements were collected and analyzed to evaluate the agreement between these 2 commonly used approaches for estimating short-term fluid changes. Agreement was assessed using Bland-Altman analysis, including regression-based evaluation of proportional bias. Clinically acceptable agreement was predefined as a difference within ± 1 kg between methods. RESULTS A total of 360 paired observations were analyzed. The mean bias between methods was small (0.082 kg), indicating minimal systematic difference at the population level. However, agreement at the individual level was poor, with wide 95% limits of agreement (-2.1 to +2.264 kg), exceeding the predefined threshold for clinical acceptability. Clinically significant disagreement (> 1 kg) occurred in 30.2% of observations. Proportional bias was present, with increasing discrepancy between methods across the range of measured values, suggesting that disagreement was not consistent across different levels of fluid change. CONCLUSIONS Routinely charted 24-hour fluid balance demonstrates clinically unacceptable agreement with body weight change and should not be considered an interchangeable measure of short-term fluid change in critically ill patients. An integrated approach combining fluid balance assessment, serial body weight measurements, and comprehensive clinical evaluation is recommended to improve assessment of fluid status and guide individualized patient management.
Autoimmune encephalitis (AIE) is a relatively new group within the spectrum of encephalitic diseases. Awareness and the pathophysiological understanding of these conditions are increasing. They are also gaining importance in the field of intensive care medicine as severe cases are frequently accompanied by unconsciousness, epileptic seizures up to treatment-refractory status epilepticus, autonomic dysregulation and the need for mechanical ventilation. A major challenge is the early differentiation between autoimmune and infectious encephalitides as symptoms, cerebrospinal fluid findings and changes in imaging examinations can often appear similar. While infectious encephalitis requires rapid anti-infective therapy, autoimmune forms necessitate early initiation of immunotherapy. Delays in commencing treatment worsen the prognosis. This article addresses the diagnostic criteria, antibody diagnostics, complications in intensive care settings and current immunotherapies.
Neurosurgical reviewElena Le Cam, Romain Salette, Lamine Abdennour, Victor Jullien, Vincent Doat Sarfati, Bertrand Mathon, Anne Laure Boch, Eimad Shotar, Frederic Clarençon, Vince…
Intracranial pressure (ICP) monitoring is a cornerstone of the management of patients with acute brain injury. External ventricular drains (EVDs) and intraparenchymal pressure sensors are the two most widely used invasive monitoring modalities. Although both techniques are routinely employed in neurocritical care, discrepancies between simultaneously recorded ICP values may occur because of technical limitations, sensor drift, or physiological intracranial pressuregradients. In this study, we evaluated dual ICP monitoring using EVD and intraparenchymal pressure sensor. The primary objective was to assess the frequency of signal mismatches. The secondary objective was to identify associations with patient diagnosis and device type. This was a single-center, retrospective observational study, from July 2013 to January 2015 and from December 2017 to April 2019. We included ICU patients with traumatic brain injury (TBI) or aneurysmal subarachnoid hemorrhage (aSAH). All patients had dual ICP monitoring with an intraparenchymal pressure sensor and an EVD. Paired ICP measurements were collected every three hours during a 15-day observation period. Three categories of discordance were analyzed: E1: absolute difference > 6 mmHg between EVD and intraparenchymal measurements E2 : EVD-positive / intraparenchymal-negative threshold discordance (EVD > 20 mmHg and intraparenchymal ICP < 20 mmHg) E3: intraparenchymal-positive / EVD-negative threshold discordance (intraparenchymal ICP > 20 mmHg and EVD < 20 mmHg). A total of 313 patients (169 traumatic brain injury and 144 aneurysmalsubarachnoid hemorrhage) were included, providing 22,294 valid paired ICP measurements. Overall, 84% (n = 267) of patients experienced at least one E1 event, whereas 15.7% (n = 49) experienced at least one E2 event and 28.1% (n = 88) at least one E3 event. Agreement between ventricular and intraparenchymal measurements remained acceptable across pathologies and device types. However, discordances occurred more frequently during episodes of intracranial hypertension. Discordance between ventricular and intraparenchymal ICP measurements was not uncommon in this cohort of neurocritical care patients. These findings underscore the complexity of ICP interpretation and highlight the limitations inherent to all invasive monitoring techniques. Although dual monitoring may help identify discordant measurements in selected situations, the clinical significance of these discrepancies and their impact on patient management and outcomes remain to be established.
Medicina intensivaVanessa Campozano, Presley Gruezo-Realpe, Israel Rosero-Basurto, Xavier Grandes, Luis Montalvo Alvarado, Francisco Mercado Villamar, Carola Giménez-Esparza, Da…
OBJECTIVE: To evaluate the clinical impact of adherence to the ABCDEF bundle in neurocritical patients admitted to an Intensive Care Unit (ICU) in Ecuador. DESIGN: A retrospective, observational, single-center study conducted between 2022 and 2024. SETTING: The ICU of a tertiary-level hospital in Guayaquil, Ecuador. PATIENTS OR PARTICIPANTS: Sixty adult neurocritical patients with ICU stays longer than 48 h were included. Patients were classified into two groups according to their adherence to the ABCDEF bundle: high adherence (≥4 components) and low adherence (≤3 components). INTERVENTIONS: Implementation of the ABCDEF bundle, including pain assessment, individualized sedation, delirium screening, early mobilization, and family participation. The main outcome measures were ICU mortality, duration of mechanical ventilation (MV), ICU length of stay, and incidence of delirium. RESULTS: High adherence was associated with a shorter MV duration (median 11 [IQR 7-15.8] vs. 15 [15-18] days; p = 0.001) and shorter ICU stay (15 [10-20] vs. 20 [18-21.8] days; p = 0.016). Mortality was lower in the high-adherence group (23.3% vs. 46.7%), although this difference was not statistically significant in the bivariate analysis (p = 0.104). In the multivariate analysis, low adherence was independently associated with higher mortality (OR: 4.51; 95%CI: 1.07-19.05; p = 0.040). The incidence of delirium was higher in the high-adherence group (53.3% vs. 0%; p < 0.001), a finding that requires further investigation to clarify its clinical significance. CONCLUSIONS: Adherence to the ABCDEF bundle was associated with improved clinical outcomes in neurocritical patients, supporting its implementation in ICUs with limited resources.
BMJ openRaphael Theilen, Robert Huhle, Martin Scharffenberg, Franziska Fischer, Tim Kramer, Thea Koch, Lorenzo Ball, Lluis Blanch, Leonardo Sarlabous, Fernando Suárez-…
INTRODUCTION: Mechanical ventilation (MV) is lifesaving in the intensive care unit (ICU) but can cause complications if not individualised according to the patient's needs. Artificial intelligence (AI)-driven decision support systems (AI-DSS) may theoretically optimise MV settings. This international observational, prospective, multicentre study aims to validate the IntelliLung AI-DSS in real clinical environments. METHODS AND ANALYSIS: In this study, patients aged ≥18 years requiring invasive MV for >24 hours are included. The primary objective is to evaluate the agreement between IntelliLung AI-DSS MV recommendations and the ventilator settings implemented by healthcare providers. The IntelliLung AI-DSS continuously analyses patient-specific data, including respiratory mechanics and gas exchange, to recommend optimal MV parameters. The primary endpoints are the relative time of matching ventilator settings for each (1) positive end-expiratory pressure, (2) fraction of inspired oxygen, (3) respiratory rate and (4) tidal volume during volume-controlled ventilation or inspiratory pressure (Pinsp) during pressure-controlled ventilation. Secondary endpoints include assessments of ventilator-free days and clinical decision-making practices. Patient-centred outcomes, such as quality of life and psychological stress, are also evaluated. Data collection spans ICU stay and follow-up at 30 and 180 days after enrolment. This trial is the first to validate the IntelliLung AI-DSS in a prospective, real-world clinical setting by comparing recommendations given by the IntelliLung AI-DSS to local standards of care. The results of the trial will serve as a foundation for future interventional studies to assess the IntelliLung AI-DSS impact on patient outcomes and ICU workflows. The study addresses a critical gap in the application of AI to intensive care, advancing personalised and evidence-based MV management. ETHICS AND DISSEMINATION: The TUD Medical Faculty Ethical Committee for clinical research approved the study on 4 November 2024 (File number Mono-EK-27907202). Additionally, the institutional review board at Sabadell, Madrid and Warsaw approved the study. IntelliLung is designed in accordance with the principles of the Declaration of Helsinki. The final main results will be published in a highly ranked, peer-reviewed scientific journal taking into account the recommendations of the International Committee of Medical Journal Editors. TRIAL REGISTRATION NUMBER: NCT06595602.
BMJ openShannon Tang, Janice Y Kung, Sarah Tymchuk, Kallirroi Laiya Carayannopoulos, M Elizabeth Wilcox
INTRODUCTION: Survivors of intensive care unit (ICU) admission and their families frequently experience persistent physical, cognitive and psychological impairments following critical illness, collectively described as post-intensive care syndrome (PICS) and post-intensive care syndrome-family (PICS-F). These sequelae often emerge during the recovery period after hospital discharge and may affect long-term functioning and quality of life. Social connectivity-the extent to which individuals maintain meaningful social relationships and supportive interactions-has been associated with improved health outcomes in several populations. This scoping review aims to map the existing literature describing social connectivity among ICU survivors and their families and examine how it has been studied in relation to recovery outcomes. METHODS AND ANALYSIS: This scoping review will be conducted using the Joanna Briggs Institute methodology for scoping reviews and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. MEDLINE, EMBASE, CINAHL and PsycINFO will be searched from database inception to December 2025 without language restrictions. Studies examining social connectivity in relation to PICS or PICS-F among adult ICU survivors or their family members will be included. Data will be extracted independently using a standardised charting form and summarised descriptively. ETHICS AND DISSEMINATION: Ethical approval is not required because this study synthesises previously published literature. Findings will be disseminated through publication in a peer-reviewed journal and may inform future research and patient- and family-centred strategies to support recovery after critical illness.
BMC geriatricsAdrian Rosada, Drin Ferizaj, Nils Lahmann, Frank Samuel Schaefer, Ursula Müller-Werdan
BACKGROUND: Physicians treating older patients are frequently unaware of their patients' personal attitudes towards life-sustaining measures like ventilation, resuscitation, feeding tubes, or ICU admission. In routine clinical practice, there is often little time for reflection prior to deciding in favor or against life sustaining measures in critical medical conditions. Although decisions for or against these measures should ideally be made jointly by the patient and the treating physician, factors like age, disease burden, social inclusion, and affective state may play an important role in the patient's motivation. METHODS: Data from 161 inpatients (mean age 82.0 years) on a geriatric ward were collected and analyzed. Patients were interviewed about their attitudes towards life-sustaining measures like ventilation, resuscitation, tube feeding, ICU admission, and dialysis. Four composite indices were formed by combining sign-aligned component variables: medical burden (age and Charlson Comorbidity Index), functional and cognitive impairment (Barthel Index, iADL, and MoCA), affective distress (Geriatric Depression Scale and Hamilton Depression Scale suicidality item), and social support (living situation, having children, and having friends). These indices with other covariates were then analyzed using a Bayesian Rasch item response model with latent regression. RESULTS: Overall, 14.3% refused all invasive life sustaining measures, whereas 33.8% wished to receive all of the measures listed above. Artificial nutrition was the most refused measure (refused by 53.4%), whereas ICU admission was the most commonly accepted measure (74.4%). Social support had no meaningful association with the decision to accept or refuse life-sustaining measures. Relevant predictors were primarily lower levels of affective distress, and secondarily better functional and cognitive performance and lower medical burden. CONCLUSIONS: Even among older patients, only a minority completely reject life-sustaining measures, even though their life expectancy is often significantly reduced. Patient's attitude towards life-sustaining measures appears to be related more strongly to affective state, functional performance, and medical burden than living situation or social inclusion. As the patient's emotional and functional state can certainly be influenced by medical treatment, practitioners should bear this in mind and, where appropriate, reassess their patients' attitude towards LSM once the aforementioned conditions have improved. CLINICAL TRIAL NUMBER: Registered with the clinical trial registry Deutsches Register Klinischer Studien.
Medical education systems vary widely across countries, yet the structure of medical and postgraduate training in China remains relatively unfamiliar to international readers. China has developed a relatively comprehensive pathway spanning undergraduate education, postgraduate programs, standardized residency training, and standardized specialty training, thereby shaping an evolving framework that aims to integrate clinical practice with scientific research. Within this framework, postgraduate nephrology education highlights both clinical training and research development. In recent years, Critical Care Nephrology has demonstrated notable strengths in the management of critical illness, blood purification, and multidisciplinary collaboration. This review provides an overview of the development, current status, and future trends in medical and postgraduate nephrology education in China, with a particular focus on the emerging role of Critical Care Nephrology.
Current neurology and neuroscience reportsMarshall Harris, Faris Almubaslat, Clio Rubinos
PURPOSE OF REVIEW: Seizures and epileptiform abnormalities (EAs) are common in critically ill patients, are frequently clinically silent, and are associated with worse outcomes. Continuous electroencephalography (cEEG) remains an essential tool in the diagnosis and management of electrographic seizures (ESz) and EAs in this population, leading to its increased use in critical settings. However, cEEG is resource-intensive, and prolonged monitoring for all patients may not be feasible or necessary in many practice environments. RECENT FINDINGS: The growing demand for cEEG in critically ill patients has created a need for strategies that optimize its use and prioritize monitoring for patients at highest seizure risk. This need has supported the development of seizure forecasting and cEEG duration-guided risk-stratification approaches. The 2HELPS2B score incorporates early EEG and clinical features to estimate seizure risk, guide monitoring duration, and supports more efficient use of cEEG resources. It has been validated and clinically implemented in critical care settings. This review outlines the evolution and importance of cEEG in critical care, beginning with the recognition that many seizures in this population are electrographic, followed by the identification of rhythmic or periodic patterns and their clinical significance, the expanding use of cEEG, the clinical characterization of patients at highest seizure risk, and the development of the 2HELPS2B score to guide efficient cEEG utilization.
Medical sciences (Basel, Switzerland)Ignacio Martin-Loeches, Hongliu Cai
Intensive care units generate dense physiological, laboratory, imaging, microbiological and treatment data, yet much of the clinical reasoning that drives decisions is recorded only in free text. Over the past decade, clinical sentiment analysis has repeatedly shown that the affective tone of nursing and medical notes is associated with mortality. The incremental discrimination over established severity scores has nevertheless been small, of the order of 0.01 in the area under the receiver operating characteristic curve in the largest published intensive care cohort, and general-purpose sentiment tools transfer poorly to critical care text. We argue that this plateau reflects a misspecified prediction target rather than a limitation of natural language processing. Mortality at 28 days is not the question the clinician asks at the bedside. We propose that the clinically useful quantity is the narrative-physiology discordance score: the signed difference, expressed on a common calibrated scale, between the short-horizon deterioration risk implied by the documented assessment and the risk implied by time-aligned multimodal data. We specify this quantity formally, fix index time and forecast horizon, and set out the leakage, copy-forward and provenance controls without which retrospective performance is uninterpretable. We then treat alert burden as a design constraint rather than a post hoc observation, deriving the operating threshold from an explicit and context-dependent alert budget, and we outline a staged evaluation pathway aligned with TRIPOD + AI and DECIDE-AI in which discordant cases are adjudicated by clinicians. Until that adjudication has been performed, discordance is a record-level inconsistency that prompts reassessment, not evidence of missed deterioration. Clinical sentiment analysis becomes useful when it stops predicting death and starts flagging disagreement.
NutrientsGeun-Hee Lee, Jeong-Hyun Park, Su-Min Kim, Joon-Ho Lee, Kyeong-Won Ryu, Jeong-Am Ryu
BACKGROUND/OBJECTIVES: Elevated gastric residual volume (GRV) is traditionally read as feeding intolerance, and randomized trials in general intensive care units (ICUs) have discredited its routine use. Whether this holds in neurocritical patients is unknown. METHODS: This exploratory, hypothesis-generating single-center retrospective cohort study comprised 355 neurosurgical ICU adults with documented GRV (2022-2026)-the exposure was a peak GRV ≥ 250 mL, the institutional feeding-hold threshold (n = 32). Three explanations were examined: prognosis (Firth penalized regression for in-hospital mortality), nutrition (standardized mean differences with causal mediation), and intracranial pathology (rank-based partial correlation between patient-level maxima of GRV and intracranial pressure (ICP) in the same early ICU window, plus trajectory phenotyping). RESULTS: Elevated GRV was not significantly associated with in-hospital mortality (adjusted odds ratio 1.46; 95% confidence interval (CI) 0.52-3.65) and was not associated with greater deterioration in laboratory-based systemic inflammatory/nutritional indices than in comparators, with null mediation. The patient-level maxima of GRV and ICP were correlated before adjustment (ρ = 0.28) and 0.19 after full adjustment (95% CI -0.001 to 0.37, p = 0.051; 10 exposed of 109), and intracranial hypertension (ICP > 22 mmHg) occurred in 90% of exposed versus 61% of unexposed monitored patients. A high-GRV trajectory phenotype was the youngest class yet showed the most frequent intracranial hypertension, although its membership and persistence were highly sensitive to missing-data handling. CONCLUSIONS: In neurocritical patients receiving enteral tube feeding with documented GRV monitoring, elevated GRV was not associated with greater deterioration in laboratory-based systemic inflammatory/nutritional indices, whereas a possible association with higher early ICP was observed in a small, monitored subset. Because the ICP-monitored subset was small, these exploratory, hypothesis-generating findings do not establish a brain-gut signal. They raise the hypothesis that elevated GRV in this setting may reflect intracranial rather than solely gastrointestinal processes and require prospective confirmation with temporally paired measurements.