Evaluating Four HIT Prediction Scores After Cardiac Surgery With Cardiopulmonary Bypass: A Comparative Study.

Genetic Syndromes Do Not Affect Survival but Increase Morbidity in Neonates with Symptomatic Tetralogy of Fallot.

Examine ICU caregivers' experience of patient-related financial strain and its association with caregiver psychological distress (i.e., posttraumatic stress, anxiety, and depressive symptoms) and healthcare perceptions (i.e., medical mistrust, decisional regret). Cross-sectional secondary analysis using baseline data from an ongoing, multicenter randomized controlled trial intervention study ( ClinicalTrials.gov identifier NCT05587517). Three medical ICU sites in the United States. Family caregivers ( n = 97) of patients in medical ICUs admitted from October 2022 to December 2025, with a mean age of 52.32 years, of whom 67 (69.1%) were female, and 42 (43.3%) were the spouse/partner of the patient. None. Caregivers completed measures assessing degree of difficulty paying for patient medical care, posttraumatic stress symptoms, anxiety symptoms, depressive symptoms, medical mistrust, and decisional regret. Analyses found 63.9% participants reported difficulty paying for patient medical care and that financial strain was positively associated with severity of posttraumatic stress symptoms ( r = 0.35; p < 0.001; 95% CI, 0.15-0.52), anxiety symptoms ( r = 0.22; p < 0.05; 95% CI, 0.02-0.41), depressive symptoms ( r = 0.27; p < 0.01; 95% CI, 0.07-0.45), decisional regret ( r = 0.30; p < 0.05; 95% CI, 0.03-0.52), and medical mistrust ( r = 0.30; p < 0.01; 95% CI, 0.10-0.48). Over half of ICU caregivers endorsed difficulty paying for patient medical care. Caregivers with greater difficulty paying for patient medical care had more severe posttraumatic stress symptoms, anxiety symptoms, and depressive symptoms; greater decisional regret; and higher levels of medical mistrust.

We describe the case of a 44-year-old female with a history significant for only hypertension who presented to the emergency department with symptoms of aphasia and difficulty concentrating, persisting for six hours. Work-up revealed evidence of a multifocal infarct suggestive of embolic etiology, along with evidence of a large 6.0 × 6.0 ascending thoracic artery and simultaneous aneurysm of the transverse arch. The patient subsequently underwent open surgical repair with placement of a Dacron graft, which she tolerated well without complications. Surgical pathology was positive for granulomatous inflammation suggestive of autoimmune or infectious etiology, and the patient was readmitted post-surgical discharge for an extensive work-up, which was found to be negative. A new diagnosis of Takayasu arteritis (TA) was made. During her subsequent hospitalization, she developed an episode of unstable atrial fibrillation with rapid ventricular response and acute hypotension requiring medical ICU observation. She was started on high-dose steroids, trimethoprim-sulfamethoxazole prophylaxis, and amiodarone with a positive clinical response. She underwent a cardiac MRI to evaluate for evidence of myocardial infiltration, which was determined to be normal. The development of atrial fibrillation was considered a postoperative complication, and amiodarone was discontinued at eight weeks. The patient received a gradual steroid taper with initiation of daily low-dose prednisone and methotrexate and made a full recovery.

Severe sepsis and septic shock frequently require escalating vasoactive support, but the prognostic utility of vasoactive-inotropic score (VIS) trajectories during polymyxin B hemoperfusion (PMX-HP) in Asian ICUs remains unclear. We conducted a retrospective single-center cohort study in a tertiary medical ICU in Taiwan, enrolling consecutive adults with severe sepsis or septic shock who received PMX-HP between July 2013 and December 2019. VIS was calculated before PMX-HP (VIS1), immediately after PMX-HP (VIS2), and approximately 24h post-treatment (VIS3); the primary outcome was 28-day all-cause mortality. In 64 patients, median VIS decreased from 28.8 (IQR 13.0-47.6) at VIS1 to 18.1 (IQR 7.8-45.0) at VIS2 and was 16.9 (IQR 1.3-45.1) at VIS3 among patients with available VIS3 data. VIS1, VIS2, and VIS3 were higher in non-survivors than survivors. A mixed-effects model using log(VIS + 1) confirmed significant effects of time, survival status, and their interaction. In an exploratory time-dependent Cox model, higher time-updated log(VIS + 1) was associated with 28-day mortality. The immediate VIS change showed limited discrimination for 28-day mortality (AUC 0.57, 95% CI 0.43-0.72), whereas VIS3 demonstrated better discrimination (AUC 0.78, 95% CI 0.66-0.91). Adding VIS3 to APACHE II improved discrimination compared with APACHE II alone (AUC 0.81 vs. 0.63; Delta AUC + 0.18; p = 0.020). Kaplan-Meier analysis using the ROC-derived VIS3 cut-off of 14.56 showed significantly worse 28-day survival when VIS3 remained above this threshold. Late post-treatment VIS monitoring may support bedside risk stratification in severe sepsis and septic shock undergoing PMX-HP; multicenter validation is warranted.Clinical trial number Not applicable.

Chronic thromboembolic pulmonary hypertension (CTEPH) is rare in children and published experience with pulmonary endarterectomy (PEA) is limited. We retrospectively reviewed six patients (<18 years) who underwent seven PEA procedures at our center between December 2011 and September 2025. Clinical characteristics, perioperative findings, hemodynamic outcomes, and follow-up data were analyzed. Median age was 13 years (range, 2-17), and five patients were female. Five had a history of pulmonary embolism, while one presented with hydatid cyst. Risk factors for CTEPH were hydrocephalus with ventriculoperitoneal shunt (n=2), hydatid cyst disease (n=1), infective endocarditis with left ventricular outflow tract obstruction (n=1), and chronic kidney disease with prior COVID-19 infection (n=1). Preoperative mean systolic pulmonary artery pressure (PAP) was 56 ± 23 mmHg, mean pulmonary artery pressure (mPAP) was 39 ± 15 mmHg, and mean pulmonary vascular resistance index (PVRi) was 7.51 ± 4.56 U·m². Most patients were in World Health Organization (WHO) functional class III or IV. All patients underwent PEA, with concomitant procedures required in most cases. Postoperatively, mPAP decreased to 21 ± 4 mmHg and mean PVRi to 2.36 ± 1.36 U·m². Median intensive care unit (ICU) and hospital stays were 3.5 and 9 days, respectively. There was one in-hospital mortality, all other patients recovered without major complications. PEA is feasible and effective in carefully selected pediatric patients, including those with complex comorbidities. Significant hemodynamic and functional improvements were achieved, supporting the role of PEA as a potentially curative therapy in this rare and challenging group.

Ovarian cancer (OC) patients admitted to the Intensive Care Unit (ICU) represent a critically ill population with significant heterogeneity, posing challenges for prognosis and personalized management. A robust subtyping system integrating multidimensional clinical data is urgently needed. This study aimed to identify and characterize distinct clinical phenotypes of OC in critical care settings and investigate their associations with outcomes and subtype-specific treatment responses. This retrospective cohort study analyzed data from 448 ICU patients with OC across two critical care databases (MIMIC-IV and eICU). We employed a Multiple Clustering Algorithms for OC Subtyping (MCAOCS) approach to identify phenotypes. The robustness of subtypes was assessed through internal and external application. Survival analysis and Inverse Probability of Treatment Weighting (IPTW) were used to evaluate mortality and treatment-exposure association. We identified two distinct clinical phenotypes from the MIMIC-IV discovery cohort (n = 259): Critical OC (n = 118) characterized by hemodynamic instability and high disease severity, and Stable OC (n = 141) with preserved organ function. The robustness and reproducibility of these phenotypes were assessed in the external eICU application cohort (n = 189). The Critical OC subtype demonstrated significantly higher mortality from 28 days to one year. Exploratory treatment-exposure analyses suggested subtype-specific associations: several ICU support and medication exposures were associated with lower 28-day mortality in the Critical OC subtype, whereas in the Stable OC subtype, only insulin and phenylephrine exposures retained statistical significance after multiple-testing correction. These findings should be interpreted as hypothesis-generating rather than causal. The MCAOCS-based binary phenotype system is robust and may have potential clinical utility, effectively stratifying ICU OC patients by mortality risk and suggesting subtype-specific treatment associations, thereby potentially facilitating precision critical care.

Objective.Atrial fibrillation (AF) is common in critically ill patients and is associated with increased mortality. Two treatment strategies are used: rhythm control and heart rate (HR) control; however, the optimal HR target in the latter remains uncertain. This study aimed to develop and compare methods for determining the target HR range using transthoracic echocardiography and physiological-signal analysis.Approach.The study was performed in a level 3 medical ICU. A custom software tool (OIIM_Python) was developed to analyse ECG, arterial pressure, and respiratory waveforms; to compute HR (HR_py) and cardiac output (CO) (CO_py). These measurements were compared with echocardiography, which provided five consecutive left ventricular outflow tract velocity-time integrals (VTI_echo) and corresponding HR (HR_echo). In phase one, 7 patients in sinus rhythm were assessed, yielding 31 paired measurements under variable preload and afterload conditions. In phase two, 13 patients with AF contributed 101 paired measurements. For both methods, mean and maximal CO were calculated, and the target HR was defined as the HR at which CO reached its maximum.Main Results.In sinus rhythm, HR_py and CO_py showed minimal bias relative to echocardiography (-1.48 bpm and-0.0003 l min-1, respectively) with clinically acceptable agreement. In AF, maximal CO_echo was significantly higher than mean CO_echo (5.24 ± 1.30 vs 4.79 ± 1.42 l min-1; +9%,p < 0.001), and target HR was significantly lower than mean HR_echo (98 ± 19 vs 110 ± 15 bpm;-11%,p < 0.001). Physiological-signal analysis similarly showed higher maximal CO_py compared with mean CO_py (6.03 ± 1.59 vs 5.32 ± 1.41 l min-1; +12%,p < 0.001), and target HR was substantially lower than mean HR_py (89 ± 17 vs 114 ± 15 bpm;-22%,p < 0.001).Significance.This feasibility study demonstrates that target HR associated with maximal CO can be estimated in critically ill patients with AF using echocardiography and/or physiological-signal analysis. These methods may support individualized HR-targeted management but require validation in larger multicentre interventional studies.

BackgroundEndotracheal tube suctioning (ETS) is a critical procedure for mechanically ventilated patients. Evidence-based guidelines exist to ensure its safe performance; however, adherence remains suboptimal, especially in resource-limited settings. This study aimed to explore the barriers to ETS guideline adherence among ICU nurses at Muhimbili National Hospital (MNH), Tanzania.MethodsAn exploratory qualitative study was conducted in the medical and surgical ICUs of MNH. Seventeen ICU nurses with ≥1 year of experience were purposively sampled. Semi-structured interviews were performed, audio-recorded, transcribed verbatim, and analyzed using inductive thematic analysis following Braun and Clarke’s framework.ResultsThree key barriers emerged: (1) Resource scarcity, including critical shortages of staff, equipment, and supplies; (2) Human and behavioral challenges, such as knowledge deficits and resistance to change away from routine practice; and (3) Guideline accessibility and usability, concerning poor accessibility and a perception that guidelines were not tailored to the local context.ConclusionNon-adherence to ETS guidelines primarily reflects systemic constraints rather than individual neglect. Strengthening adherence requires multi-level interventions: improving staffing and resources, providing continuous training, and adapting international guidelines to the local context.

Association between bedside medical toxicology consultation and hospital triage and resource utilization for poisoned patients.

During intensive care unit bed shortages, it is recommended that critically ill patients be cared for in the emergency department. Clarity is needed regarding admissions to the medical intensive care unit from the emergency department. To standardize treatment of critically ill patients and reduce time to critical care consultation through an interdepartmental model. Time to critical care consultation, intensive care unit length of stay, and proportion of short-stay intensive care unit admissions were evaluated before and after model implementation. Mean time to consultation decreased significantly from before to after model implementation (113.9 vs 56 minutes). Mean intensive care unit length of stay increased from 2.8 to 3.4 days. The proportion of intensive care unit short stays decreased from 21.3% to 19.2%. The interdepartmental care model expedited critical care for boarding emergency department patients, increased intensive care unit length of stay, and slightly reduced short-stay admissions.

IntroductionTransitions of care among ICU physicians have been shown to negatively affect care processes and could impact clinical outcomes. Liberation from mechanical ventilation is a judgment-based decision and may be delayed when continuity is disrupted by physician handoffs.ObjectiveTo assess the association between attending physician transitions of care and liberation of patients from mechanical ventilation.MethodsRetrospective cohort study. Patients were included if they were admitted to one of three medical ICUs and received mechanical ventilation between January 2022 and May 2025. Transition days were defined as any day where the daytime attending intensivist was different than the day prior. Transition days were identified by review of schedules recorded on the online scheduling system.ResultsOf 3657 ICU days were analyzed, 2732 (74.7%) occurred on non-switch days and 925 (25.3%) on transition days. There were no ventilator liberations on 497 (53.7%) transition days, 1 liberation on 292 (31.56%) transition days, 2 liberations on 105 (11.4%) transition days, and >2 liberations on 31 (3.4%) days. Among non-transition days, there were 0 (1356 [49.6%]), 1 (920 [33.7%], 2 (357 [13.1%]), and >2 (99 [3.6%]) ventilator liberations per day. Transition days were associated with a 10% lower rate of liberations per ICU-day (aIRR 0.90, 95%CI 0.88-0.91, p < 0.01). There was no association between transition day and reintubation (aIRR 0.91, 95% CI 0.73-1.13).ConclusionsAttending physician transition days were associated with a reduction in rates of ventilator liberation. Physician transition is a potentially modifiable contributor to delayed liberation from mechanical ventilation.

Association of phosphate decline after nutritional support with extubation failure in critically ill patients.

Acute kidney injury (AKI) is a common complication in critically ill patients with decompensated cirrhosis who often require kidney replacement therapy (KRT) but prognostic uncertainty remains in critically ill ICU patients, particularly regarding short- and medium- term outcomes after KRT initiation. We conducted a retrospective, single center cohort analysis of critically ill patients with cirrhosis and AKI requiring KRT in the medical ICU of a tertiary care liver transplant center. We gathered data pertaining to CLIF-C ACLF and MELD-Na on the day of ICU admission. Survival outcomes of interest included days to death from the start of KRT, and at one- and six-month interval. 131 patients met the inclusion criteria of which 21 were listed for liver transplantation at time of ICU admission. 86.3% of patients were diagnosed with acute tubular necrosis (ATN) and the remaining with HRS-AKI. 69.5% of patients were prescribed Continuous Veno Venous Hemofiltration (CVVH) as initial KRT modality. Mean clinical severity scores were MELD-Na 33.1 (SD 8.3) and CLIF-C ACLF score 63.4 (SD 10.3). 21.4% and 15.3% of the 131 patients included, were alive at 1 and 6 months after ICU admission. Median survival time from KRT initiation in ICU was 5 days (IQR 3-12.5 days). Survival did not differ significantly by AKI etiology or transplant listing status although this is limited by small sample size and dynamic nature of transplant listing status. In unadjusted analyses, survival differed by initial KRT modality, with higher mortality among patients initiated on CVVH; however, in multivariable Cox regression, only CLIF-C ACLF score [HR 1.03 (1.00- 1.05), p = 0.04], platelets [HR 0.997 (0.994-0.999), p = 0.02] and INR [HR 1.22 (1.00-1.49), p = 0.05] were significantly associated with survival time. AKI requiring KRT in critically ill patients with cirrhosis is associated with limited survival. Mortality was primarily associated with overall severity of acute-on-chronic liver failure, as reflected by CLIF-C ACLF score, rather than MELD-Na. No clear differences were observed by AKI etiology or transplant listing status. Although unadjusted survival differed by initial KRT modality, this likely reflects confounding by illness severity rather than a modality-specific effect. Not applicable.

Blood culture contamination (BCC) is a challenging issue that can negatively impact patients and healthcare costs. The Clinical and Laboratory Standards Institute (CLSI) historically encouraged a BCC rate of <3%, although recent evidence suggests <1% is achievable. One approach to reducing BCC is initial specimen blood diversion devices (ISDDs). ISDDs prevent the initial blood, which may contain contaminating microorganisms, from inoculating the blood bottles. The ISDD literature remains limited, particularly for evaluating performance across different wards. Here, the Kurin Lock ISDD was evaluated in an emergency department (ED), cardiothoracic intensive care unit (CTICU), and medical intensive care unit (MICU). A comparison of 6 months pre- and post-implementation revealed a 35.3% BCC reduction overall (P = 0.016), with variation across wards: ED 41.0% (P = 0.043), CTICU 38.7% (P = 0.20), and MICU 20.3% (P = 0.61). Device compliance rates varied by ward: ED (62.5%), CTICU (32.2%), and MICU (35.4%). When post-implementation cultures were segregated by ISDD usage, the MICU BCC rate was 0.39% versus 3.02% without ISDD usage (P = 0.025). The ED and MICU also had multiple months below 1%. The CTICU did not have a month below 1% nor a significant BCC rate difference post-implementation with or without ISDD usage (2.52% and 3.19%, P > 0.99). Furthermore, an estimated $170,378 of contamination costs were avoided using a cost per contamination of $6,553 from a prior meta-analysis. Given our low ISDD compliance, contamination rates and financial savings can still be improved. Taken together, ISDDs are a promising approach to lower BCC rates and costs, although impact may vary by ward.IMPORTANCEHealthcare systems continue to strive toward a <1% blood culture contamination rate. Initial specimen blood diversion devices (ISDDs) are a promising approach to achieve this goal; however, data remain limited on small-volume ISDDs, especially in different hospital ward settings. Here, we found the small-volume Kurin Lock ISDD reduced blood culture contamination rates and theoretically avoided contamination costs, despite low ISDD compliance. Importantly, performance varied considerably across an emergency department and two intensive care units. While the presented findings support ISDD usage, health systems must be mindful of variable ward performance and manage expectations accordingly.

Body weight definitions for estimating energy expenditure in intensive care, a prospective monocentric observational study.

Evidence is lacking to appraise whether radial access should be preferred to femoral access for coronary angiography (CAG) in critically ill patients. Patients admitted to the medical intensive care unit (ICU) of a university hospital over a 5-year period and requiring CAG immediately before or during the ICU stay were retrospectively included. The average treatment effect of the arterial route used for CAG was assessed through a win-ratio methodology with propensity score (PS)-based inverse probability of treatment weighting (IPTW). The primary endpoint was a hierarchical composite outcome of (i) all-cause death, (ii) resuscitated cardiac arrest, (iii) stroke, (iv) myocardial infarction, (v) acute limb ischemia and/or need for vascular surgery on CAG access site and (vi) Bleeding Academic Research Consortium (BARC) type 3 major bleeding, all assessed at day 28. The relationship between access site and the likelihood of all-cause death at day 28 was investigated with a Cox proportional hazard model stratified on the occurrence of cardiac arrest before CAG and adjusted through PS-based IPTW. Among the 235 included patients (116 with femoral access and 119 with radial access), 145 (61.7%) were admitted following cardiac arrest and 116 (49.4%) presented with cardiogenic shock at the time of CAG. The primary composite endpoint occurred in 63.4% of patients with femoral access and 47.7% of patients with radial access in IPT-weighted populations (absolute risk difference 15.6%, 95% confidence interval [CI] 1.4% to 29.8%, P = 0.03; win ratio for femoral versus radial access 0.62, 95% CI 0.40 to 0.98, P = 0.04). Access site complications were more frequent in patients with femoral access while major bleedings were similarly observed in both groups. Femoral access was not associated with day-28 mortality (adjusted hazard ratio 1.43, 95% CI 0.90 to 2.26, P = 0.13). Percutaneous coronary revascularisation and implantation of veno-arterial extra-corporeal membrane oxygenation, when required, were not hastened with femoral access. In this study, the use of a femoral rather than radial approach for CAG in critically ill patients was associated with a higher incidence of access site complications but did not correlate with the hazard of major bleeding or all-cause death at day 28.

Efficient use of intensive care unit (ICU) resources requires accurate prediction of length of stay (LOS), yet existing LOS models show inconsistent performance across settings and may not generalize to Japanese ICUs. We conducted a retrospective cohort study using the Japanese Intensive Care Patient Database, including adults admitted to 87 ICUs between April 2022 and March 2023. The primary outcome was ICU LOS in days. Generalized additive models with several distributional assumptions were fitted using the Acute Physiology and Chronic Health Evaluation III score, primary disease category, emergency surgery status, and admission source as predictors. Model performance was evaluated using deviance explained with internal validation. The best-performing model was applied to derive ICU-level standardized length-of-stay ratios (SLOSR) and observed minus expected length of stay (OMELOS), summarized using funnel plots with and without overdispersion correction. Among 65,395 patients, median ICU LOS was 3 days (interquartile range: 2-5). A gamma model with a log link achieved the highest cross-validated deviance explained (0.415). Overdispersion correction reduced the proportion of ICUs exceeding the 95% control limits from 69% to 9.2%. These findings indicate that a gamma-based generalized additive model enables case-mix-adjusted ICU LOS benchmarking and that overdispersion correction substantially affects outlier identification.

Vancomycin-resistant Enterococcus (VRE) infection poses a significant healthcare burden in intensive care units (ICUs), and is preceded by gut colonization. The gut microbiome may influence susceptibility to VRE, but its role in ICU patients remains incompletely defined. We conducted a prospective study of patients admitted to a medical ICU from 2019 to 2021. Stool samples were collected for bacterial 16S rRNA gene sequencing, anal swabs were screened for VRE by culture, and bile acids were measured in initial stool samples. We enrolled 108 patients. Thirty-four patients were VRE + on initial screen and remained so (VRE+/+) while 74 were initially negative, of whom 23 acquired VRE (VRE-/+) and 51 remained negative (VRE-/-). There was no difference in alpha-diversity initially between VRE-/- and VRE-/+ groups, whereas VRE+/+ patients had significantly lower alpha-diversity (P < 0.001). VRE-/+ patients had a significantly more rapid decrease in alpha-diversity than VRE-/- patients (P = 0.04). Beta-diversity of initial stool differed among groups (P = 0.001), driven mainly by VRE+/+ patients. A lower Bacteroides/Enterococcus ratio (P = 0.049) and low Clostridium scindens abundance (P = 0.031) were associated with VRE acquisition. Initial stool from VRE-/- patients had a higher combined concentration of deoxycholic acid and lithocholic acid than that of VRE-/+ patients (P = 0.034). VRE acquisition in the ICU was associated with an initial gut microbiome characterized by lower Bacteroides/Enterococcus ratios, lower C. scindens abundance, and lower deoxycholic and lithocholic acid concentrations. Our findings are consistent with a possible role of these microbiome features in colonization resistance, as suggested by in vitro and animal models. However, given the single-center design, these associations should be considered hypothesis-generating and require validation before clinical application.

Previous retrospective studies involving mixed intensive care unit (ICU) populations found antipsychotic continuation rates ranging from 21% to 61% at hospital discharge. Surgical ICU admission was cited as a risk factor for antipsychotic continuation, although data in the trauma population are limited. The purpose of this study was to evaluate the number of critically ill trauma patients with escalated psychotropic medications in the surgical ICU and the rate of continuation at ICU transfer and hospital discharge. This single-center, retrospective, Institutional Review Board (IRB)-approved study examined adult trauma patients admitted to the surgical ICU at an urban Level 1 Trauma and Academic Medical Center from December 1, 2021, to May 31, 2023. Patients were excluded if they had a history of select psychiatric disorders or were in the ICU for less than 48 hours. Prior psychotropic medication use was noted, and escalation was defined as a new or increased dose of psychotropic medication. The incidence of delirium and agitation was recorded to assess the indication for psychotropic medication escalation. The primary and secondary outcomes were the percentage of patients with escalated psychotropic medications in the ICU who were continued on therapy at the time of ICU transfer and hospital discharge, respectively. Four hundred and twenty-four patients admitted to the surgical ICU were included; 51.4% were escalated on a psychotropic medication while in the ICU. Nearly 35% and 31.8% of the overall population were continued on psychotropic medication at ICU and hospital discharge, respectively. Of patients on psychotropic medication at hospital discharge, 55.6% were discharged to acute rehabilitation, 28.9% to home, and 13.3% to long-term care. Escalation of psychotropic medications was common in trauma patients admitted to the surgical ICU. Further investigation into the appropriateness of psychotropic medication prescription during care transitions is needed.