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Topic Review
Neuromuscular Blocking Agents
The use of neuromuscular blocking agents (NMBAs) is common in the intensive care unit (ICU). NMBAs have been used in critically ill patients with lung diseases to optimize mechanical ventilation, prevent spontaneous respiratory efforts, reduce the work of breathing and oxygen consumption, and avoid patient–ventilator asynchrony.
  • 789
  • 06 Mar 2024
Topic Review
Septic Acute Kidney Injury
Sepsis is a life-threatening condition that results from a profoundly dysregulated response to infection. It can lead to organ failure distant from the primary site of the infection, particularly in the kidneys. Sepsis can cause acute kidney injury (AKI). Sepsis and AKI form a vicious cycle, as sepsis is one of the main drivers of critical illness.
  • 788
  • 08 Nov 2023
Topic Review
Endotoxin Adsorption in the Treatment of Septic Shock
Lipopolysaccharide, the main component of the outer membrane of Gram-negative bacteria is a highly potent endotoxin responsible for organ dysfunction in sepsis. It is present in the blood stream not only in Gram-negative infections, but also in Gram-positive and fungal infections, presumably due to sepsis-related disruption of the intestinal barrier. Various pathways, both extra- and intracellular, are involved in sensing endotoxin and non-canonical activation of caspase-mediated pyroptosis is considered to have a major role in sepsis pathophysiology. Endotoxin induces specific pathological alterations in several organs, which contributes to poor outcomes. The adverse consequences of endotoxin in the circulation support the use of anti-endotoxin therapies, yet more than 30 years of experience with endotoxin adsorption therapies have not provided clear evidence in favor of this treatment modality. The results of small studies support timely endotoxin removal guided by measuring the levels of endotoxin; unfortunately, this has not been proven in large, randomized studies. The presence of endotoxemia can be demonstrated in the majority of patients with COVID-19, yet only case reports and case series describing the effects of endotoxin removal in these patients have been published to date. The place of blood purification therapies in the treatment of septic shock has not yet been determined.
  • 785
  • 16 Feb 2022
Topic Review
Targeted Temperature Management
International guidelines recommend targeted temperature management (TTM) to improve the neurological outcomes in adult patients with post-cardiac arrest syndrome (PCAS). Several studies have indicated that the beneficial effect of hypothermic TTM differs according to the severity of PCAS, suggesting that there may be a subgroup of PCAS patients that is especially likely to benefit from hypothermic TTM. 
  • 773
  • 13 Dec 2021
Topic Review
ICU-Acquired Colonization and Infection in COVID-19 Patients
A large proportion of ICU-acquired infections are related to multidrug-resistant bacteria (MDR). Infections caused by these bacteria are associated with increased mortality, and prolonged duration of mechanical ventilation and ICU stay.  Although a huge amount of literature is available on COVID-19 and MDR bacteria, only a few clinical trials have properly evaluated the association between them using a non-COVID-19 control group and accurate design and statistical methods. The results of these studies suggest that COVID-19 patients are at a similar risk of ICU-acquired MDR colonization compared to non-COVID-19 controls. However, a higher risk of ICU-acquired infection related to MDR bacteria has been reported in several studies, mainly ventilator-associated pneumonia and bloodstream infection. Several potential explanations could be provided for the high incidence of ICU-acquired infections related to MDR. Immunomodulatory treatments, such as corticosteroids, JAK2 inhibitors, and IL-6 receptor antagonist, might play a role in the pathogenesis of these infections. Additionally, a longer stay in the ICU was reported in COVID-19 patients, resulting in higher exposure to well-known risk factors for ICU-acquired MDR infections, such as invasive procedures and antimicrobial treatment. Another possible explanation is the surge during successive COVID-19 waves, with excessive workload and low compliance with preventive measures. Further studies should evaluate the evolution of the incidence of ICU-acquired infections related to MDR bacteria, given the change in COVID-19 patient profiles. A better understanding of the immune status of critically ill COVID-19 patients is required to move to personalized treatment and reduce the risk of ICU-acquired infections. The role of specific preventive measures, such as targeted immunomodulation, should be investigated.
  • 773
  • 27 Sep 2023
Topic Review
Therapeutic Drug Monitoring of Beta-Lactam Antibiotics
Here describes various aspects of beta-lactams use in the critical care, focusing on clinical antibiotic stewardship in the ICU. Pharmacokinetics / pharmacodynamics (PK/PD) characteristics of beta-lactams are described and main factors of PK/PD variability in critically ill patients. Toxicity of beta-lactams, a frequently overlooked issue, is outlined. Analytical methods used in therapeutic drug monitoring (TDM) of beta-lactams are discussed. The evidence supporting antibiotic guidance based on therapeutic drug monitoring (TDM) in critically ill patients is analysed.
  • 770
  • 19 Jun 2023
Topic Review
Therapeutic Plasma Exchange in the ICU
Therapeutic plasma exchange (TPE) is a treatment paradigm used to remove harmful molecules from the body. In short, it is a technique that employs a process that functions partially outside the body and involves the replacement of the patient’s plasma. It has been used in the ICU for a number of different disease states, for some as a first-line treatment modality and for others as a type of salvage therapy. 
  • 767
  • 09 Jan 2024
Topic Review
Lung Microbiome in Critically Ill Patients
The microbiome is a diverse ecosystem that includes all host-associated microorganisms and their genomes. These microorganisms belong to various kingdoms including some potential pathogens such as bacteria, viruses and fungi. To obtain a comprehensive view of the lung microbiome, including not only bacterial but also viral and fungal data, is of great value to improve our understanding of critical lung illnesses such as VAP or ARDS. The evolution of the lung microbiome over time and the description of its dysbiosis will be key elements to improve diagnosis and preventive measures in ventilated patients.
  • 761
  • 24 Jan 2022
Topic Review
Surfactant Abnormalities in Acute Respiratory Distress Syndrome
Acute respiratory distress syndrome (ARDS) is a major cause of hypoxemic respiratory failure in adults, leading to the requirement for mechanical ventilation and poorer outcomes. Dysregulated surfactant metabolism and function are characteristic of ARDS. A combination of alveolar epithelial damage leading to altered surfactant synthesis, secretion, and breakdown with increased functional inhibition from overt alveolar inflammation contributes to the clinical features of poor alveolar compliance and alveolar collapse.
  • 749
  • 27 Oct 2023
Topic Review
The Relationship between Hypercarbia and Hypoxia
Ventilation and gas exchange are fundamental to maintaining proper levels of oxygen (PaO₂) and carbon dioxide (PaCO₂) in the blood. Minute ventilation (V̇E), the total volume of air moved in and out of the lungs per minute, is normally around 5-8 L/min in healthy adults. However, only a portion of this air reaches the alveoli for gas exchange, a process known as effective alveolar ventilation (V̇A), which is crucial for regulating PaCO₂ levels. When effective ventilation is reduced or dead space in the lungs increases, carbon dioxide clearance decreases, leading to elevated PaCO₂, known as hypercapnic respiratory failure. Hypercapnic respiratory failure occurs due to two main mechanisms: decreased effective alveolar ventilation or increased dead space. Reduced ventilation may result from a lower respiratory rate or smaller tidal volumes, often caused by sedative drugs, brainstem injuries, neuromuscular weakness, or physical factors such as obesity. Alternatively, conditions like COPD or acute respiratory distress syndrome (ARDS) increase dead space, meaning more of the inhaled air does not participate in gas exchange due to inadequate blood perfusion in certain lung areas. This dead space effect prevents sufficient CO₂ elimination, even if minute ventilation is normal or elevated. Patients with chronic hypercapnia, such as those with advanced COPD, may tolerate higher levels of PaCO₂ (90-120 mm Hg) without symptoms. In contrast, healthy individuals typically begin to experience symptoms of hypercapnia when PaCO₂ rises above 70-80 mm Hg. On the oxygen side, the alveolar gas equation helps explain how PaO₂ depends on both inspired oxygen and the amount of carbon dioxide in the alveoli. Inadequate oxygen levels, or hypoxemia, can occur when effective ventilation is compromised, as seen in conditions that reduce alveolar ventilation or increase dead space.
  • 722
  • 11 Nov 2024
Topic Review
Management Strategies in Septic Coagulopathy
One of the ‘organs’ that can be affected by sepsis is the coagulation system. Coagulopathy in sepsis may take the form of sepsis-induced coagulopathy (SIC) or sepsis-associated disseminated intravascular coagulation (DIC). It is important to identify SIC early, as at this stage of coagulopathy anticoagulants may be of the greatest benefit. The mainstream management strategies in septic coagulopathy include the causal treatment of sepsis, unfractionated heparin, low-molecular-weight heparin, antithrombin, and recombinant human thrombomodulin. The last two have been associated with the highest survival benefit. Nevertheless, the indiscriminate use of these anticoagulants should be avoided due to the lack of mortality benefit and increased risk of bleeding. The early diagnosis of SIC and monitoring of coagulation status during sepsis is crucial for the timely management and selection of the most suitable treatment at a time. 
  • 717
  • 01 Feb 2023
Topic Review
Pain Management at the End of Life
Access to pain management is a fundamental human right for all people, including those who are at the end of life (EOL). In end-stage patients, severe and uncontrolled pain is a common cause of admission to the emergency department (ED), and its treatment is challenging due to its complex, often multifactorial genesis.
  • 704
  • 14 Jul 2023
Topic Review
Adjunctive Hemoadsorption Therapy with CytoSorb in Septic/Vasoplegic Shock
There are no approved therapies to modulate the excessive immune response and limit hyperinflammation with the goal of preventing related organ failure and death. In this context, extracorporeal blood purification therapies aiming at the alteration of the host inflammatory response through broad-spectrum, non-selective removal of inflammatory mediators have come into focus. A novel hemoadsorption device (CytoSorb®, CytoSorbents Inc., Princeton, NJ, USA) has shown promising results in patients with hyperinflammation from various origins. Although a significant body of literature exists, there is ongoing research to address many important remaining questions, including the optimal selection of patient groups who might benefit the most, optimal timing for therapy initiation, optimal schedule for adsorber exchanges and therapy duration, as well as an investigation into the potential removal of concomitant antibiotics and other medications. 
  • 696
  • 04 Dec 2023
Topic Review
Necessity of Cardiothoracic Surgical Critical Care Medicine Training
Cardiothoracic surgical critical care medicine is practiced by a diverse group of physicians including surgeons, anesthesiologists, pulmonologists, and cardiologists. With a wide array of specialties involved, the training of cardiothoracic surgical intensivists lacks standardization, creating significant variation in practice. Additionally, it results in siloed physicians who are less likely to collaborate and advocate for the cardiothoracic surgical critical care subspeciality. Moreover, the current model creates credentialing dilemmas, as experienced by some cardiothoracic surgeons. 
  • 680
  • 01 Jan 2023
Topic Review
Artificial Intelligence in the Intensive Care Unit
The development of artificial intelligence (AI) allows for the construction of technologies capable of implementing functions that represent the human mind, senses, and problem-solving skills, leading to automation, rapid data analysis, and acceleration of tasks. These solutions has been initially implemented in medical fields relying on image analysis; however, technological development and interdisciplinary collaboration allows for the introduction of AI-based enhancements to further medical specialties. During the COVID-19 pandemic, novel technologies established on big data analysis experienced a rapid expansion. Yet, despite the possibilities of advancements with these AI technologies, there are number of shortcomings that need to be resolved to assert the highest and the safest level of performance, especially in the setting of the intensive care unit (ICU). Within the ICU, numerous factors and data affect clinical decision making and work management that could be managed by AI-based technologies. Early detection of a patient’s deterioration, identification of unknown prognostic parameters, or even improvement of work organization are a few of many areas where patients and medical personnel can benefit from solutions developed with AI.
  • 673
  • 05 Jun 2023
Topic Review
Postoperative Cognitive Dysfunction Management in Cirrhotic Patients
Postoperative cognitive dysfunction (POCD) represents a decreased cognitive performance in patients undergoing general anesthesia for major surgery. Since liver cirrhosis is associated with high mortality and morbidity rates, cirrhotic patients also assemble many risk factors for POCD. Therefore, preserving cognition after major surgery is a priority, especially in this group of patients. POCD is roughly defined as decreased cognitive performance in patients undergoing anesthesia. Various risk factors, including increased age, baseline cognition level, depth of anesthesia, or postoperative pain level, were described to be involved in the development of POCD. In the cirrhotic patient, POCD is described as a “more than expected” decline in cognitive function. The judicious use of anesthetic agents and techniques, the monitoring of the depth of anesthesia, and the application of ERAS protocols may prove to be advantageous in this setting. However, specific and targeted therapies for POCD are lacking. 
  • 663
  • 16 Jun 2023
Topic Review
Telemedicine in Providing Palliative Care to Cancer Patients
Telemedicine, or the use of telecommunications to provide health services, is a technology that has been long studied to help increase access to health care.
  • 658
  • 16 May 2022
Topic Review
Antibiotic Therapy of Sepsis Stewardship
The main recent change observed in the field of critical patient infection has been the universal awareness of the need to make better use of antimicrobials, especially in the most seriously ill patients, beyond the application of simple formulas and rigid protocols. The greatest challenge, therefore, of decision making in this context lies in determining an effective, optimal, and balanced empirical antibiotic treatment. This is sepsis stewardship.
  • 627
  • 07 Feb 2024
Topic Review
Analgesics Fact Sheet
This guide provides a structured, decision-oriented approach to the use of analgesics across common categories: Acetaminophen, NSAIDs, Opioids, Antiepileptics, Antidepressants, and Corticosteroids. It outlines specific pain types, conditions, and scenarios where each drug class is effective, key contraindications and risk factors for each category, standard therapeutic dosing to ensure safe and effective treatment. Designed for quick clinical reference, this fact sheet emphasizes practical applications, focusing on analgesic choice tailored to pain type, patient comorbidities, and safety considerations.
  • 620
  • 27 Nov 2024
Topic Review
Pathophysiology of Acute Kidney Injury
In clinical practice, one of the most common interventions is volume expansion in those with perceived hypovolemia. Intravenous fluid administration is easily performable with crystalloid and colloid infusions or with various blood products. In the era, the isotonic but non-physiologic 0.9% saline and balanced solutions are available as crystalloid infusions, whereas the 6% hydroxyethyl starch (HES) (130/0.4 or 0.42) and the 5% or 20% human albumin are available as colloids, respectively.
  • 618
  • 21 Aug 2023
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