Author Archives: administrare

Evidence-based fluid resuscitation of the septic HFpEF patient: A narrative review of the literature

Maxwell Ward, Roshan Acharya, Anthony Loschner

Virginia Polytechnic Institute and State University, Carilion School of Medicine, Roanoke, Virginia, USA

DOI: 10.2478/jccm-2026-0005

Purpose: This narrative review aims to highlight the available evidence on fluid resuscitation in septic patients with heart failure, with a particular focus on heart failure with preserved ejection fraction.
Methods: A PubMed search was conducted using the keywords “sepsis” (or sepsis, or septic shock), “heart failure” (or HF, or HFrEF, or HFpEF or congestive heart failure), and “fluid” (or resuscitation, or fluid resuscitation, or fluid management). The results were summarized in narrative review format.
Results/Conclusions: The presence of HFpEF in septic patients appears to be associated with an increased risk of adverse outcomes. This population may benefit from a more individualized approach to fluid resuscitation. Emerging tools for assessing fluid responsiveness and characterizing septic cardiovascular physiology show promise, but further investigation is needed.

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Transition from ICU to home care with long-term invasive ventilation using a single-limb BiPAP circuit

Mircea Stoian1, Nicolae Demenciuc2, Sergiu-Stefan Laszlo3, Anca Motataianu4, Dragoș-Florin Babă5, Adina Stoian6

1 Department of Anesthesiology and Intensive Care, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Targu Mures, Romania
2 Pneumology Department, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Targu Mures, Romania
3 Mures County Hospital, Targu Mures, Romania
4 Department of Neurology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Targu Mures, Romania
5 Emergency Institute for Cardiovascular Diseases and Transplantation, Targu Mures, Romania
6 Department of Pathophysiology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Targu Mures, Romania

DOI: 10.2478/jccm-2026-0004

Background: Patients with chronic respiratory failure caused by severe neuromuscular impairment often require long-term respiratory support. Invasive mechanical ventilation (IMV) via tracheostomy is usually provided in intensive care units (ICUs), but in carefully selected cases, it can be safely transitioned to home care. The use of a single-limb ventilator circuit (Single BiPAP circuit with Whisper Swivel II), intended initially for non-invasive ventilation (NIV), may represent a cost-effective and practical alternative for long-term home IMV.
Case presentation: We present a 50-year-old male with progressive neuromuscular disease and chronic respiratory failure, who required long-term IMV through a tracheostomy tube. After stabilization in the ICU, ventilation was maintained at home using a Single BiPAP circuit with Whisper Swivel II, combined with a mechanical insufflation-exsufflation (MIE) device for airway secretion clearance. The patient’s family received structured training in tracheostomy care, ventilator operation, and secretion management. Over 32-month period, the patient maintained stable respiratory function, experienced a marked reduction in infectious exacerbations, and preserved an acceptable quality of life.
Conclusion: In selected patients, long-term home IMV using a single-limb ventilator combined with an MIE device can be a safe, effective, and cost-efficient alternative to conventional ICU-based ventilation. Successful outcomes require structured patient and caregiver training, close follow-up, and coordinated multidisciplinary support.

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Interruption of enteral tube feeding during chest physiotherapy in critically ill adults: A scoping review

Ruvistay Gutierrez-Arias1, Francisco Salinas-Barahona2, Pamela Seron3

1 Departamento de Apoyo en Rehabilitación Cardiopulmonar Integral, Instituto Nacional del Tórax, Santiago, Chile; INTRehab Research Group, Instituto Nacional del Tórax, Santiago, Chile; Exercise and Rehabilitation Sciences Institute, School of Physical Therapy, Faculty of Rehabilitation Sciences, Universidad Andres Bello, Santiago, Chile
2 Departamento de Apoyo en Rehabilitación Cardiopulmonar Integral, Instituto Nacional del Tórax, Santiago, Chile; INTRehab Research Group, Instituto Nacional del Tórax, Santiago, Chile; Escuela de Kinesiología, Universidad de Las Américas, Santiago, Chile
3 Departamento de Ciencias de la Rehabilitación, Facultad de Medicina, Universidad de La Frontera, Temuco, Chile; Centro de Excelencia CIGES, Facultad de Medicina, Universidad de La Frontera, Temuco, Chile

DOI: 10.2478/jccm-2026-0002

Introduction: Numerous reports indicate that the nutritional targets of critically ill patients are frequently not met. In daily clinical practice, it is often recommended to temporarily stop enteral tube feeding in patients on mechanical ventilation (MV) who are undergoing chest physiotherapy. This is because adverse events can occur and potentially cause vomiting and increase the risk of aspiration pneumonia.
Aim of the study: To identify, characterise, and analyse the available evidence on the interruption of enteral tube feeding in critically ill adult patients receiving MV before or during chest physiotherapy.
Materials and Methods: We conducted a scoping review following the recommendations of the Joanna Briggs Institute. We conducted a systematic search of MEDLINE (Ovid), Embase (Ovid), CENTRAL (Cochrane Library), CINAHL (EBSCOhost), and other search resources until March 2025. We included studies of any design that addressed the application of chest physiotherapy in adults on MV and receiving enteral tube nutrition. Study selection and data extraction were performed in duplicate, and disagreements were resolved by consensus.
Results: We include four studies that were published between 2018 and 2024. One observational study reported that enteral tube feeding was discontinued due to the application of chest physiotherapy in patients in prone and supine MV. In the other three studies, which contribute to a clinical practice guideline, discontinuation of enteral tube feeding is recommended 30 minutes before using the head-down position as a bronchial drainage manoeuvre. However, no studies report on the safety of chest physiotherapy when enteral tube feeding is either discontinued or continued.
Conclusion: There is no empirical evidence to justify routinely stopping enteral tube feeding during chest physiotherapy in MV patients. Future primary studies should report on the management of enteral tube feeding before or during chest physiotherapy interventions, as well as document any adverse events that may occur during its application.

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Efficacy of inhaled antibiotics in children with ventilator-associated pneumonia: A systematic review and meta-analysis

Sher W. Chee1, Rafdzah A. Zaki2, Shih Y. Hng1, Kah P. Eg1, Qiao Y. Lee1, Jessie A. de Bruyne1, Anna Marie Nathan1

1 Department of Pediatrics, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
2 Department of Social and Preventive Medicine, Centre of Epidemiology and Evidence-Based Practice, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia

DOI: 10.2478/jccm-2026-0003

Introduction: The nebulization of antibiotics allows the delivery of high concentration of medication to the lungs without the systemic side-effects.
Aims: We performed a systematic review and meta-analysis to determine the efficacy and safety of inhaled antibiotics in children with ventilator-associated pneumonia (VAP).
Data sources: We searched Web of Science, SCOPUS, MEDLINE Complete, CINAHL and ClinicalTrials.gov trials registry until June 2025. This study was registered (CRD42024504982).
Study selection: We included studies published in the last ten years that recruited children under 18 years old with VAP and treated with inhaled antibiotics. We excluded studies of children with tracheostomy and bronchiectasis.
Data extraction: Type of intervention (inhaled ± intravenous (IV) antibiotics), clinical improvement, duration of mechanical ventilation (MV) and hospitalization, bacterial eradication, and adverse events were recorded.
Results: Seven articles (346 patients) reported the use of inhaled antibiotics in VAP, of which four were randomized controlled trials. These studies included premature infants, neonates and children. The commonest inhaled antibiotic used was colistin (six studies). Meta-analysis revealed that inhaled antibiotics + IV antibiotics versus IV antibiotics +/- inhaled normal saline(placebo) resulted in no significant reduction in duration of MV (MD 0.88 days, 95% CI -2.72, 4.49; p=0.63, I2 = 85%) and ICU stay (MD 0.34[-2.79,3.40]; p=0.83, I2 = 80%). Clinical success (RR 0.68, 95% CI 0.39, 1.21; p=0.19, I2 =24%), microbiological eradication (RR 1.93, 95%CI 0.97,3.78; p=0.06, I2 = 2%) and mortality (RR 0.91, 95% CI 0.67, 1.24; p=0.54, I2 =0%) were also not significantly different. Inhaled antibiotics were not associated with increased nephrotoxicity (RR 0.91, 95% CI 0.18, 4.61; p=0.91, I2 = 30%)
Conclusion: More robust studies are required to confirm the clinical efficacy of inhaled antibiotics in the treatment of VAP. Nonetheless, adjunctive inhaled antibiotics may be safe in children, although close monitoring is still required.

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Pharmacokinetic-guided magnesium prophylaxis in cardiac surgery: A randomized trial demonstrating guideline-level reductions in atrial fibrillation, accelerated recovery, and systemic cost savings

Sarah Hamdy Elghareeb, Islam Taher, Ahmed Abd Al Ghany, Noha Mohamed Abdelaziz

Ain Shams University Faculty of Medicine, Cairo, Egypt

DOI: 10.2478/jccm-2026-0001

Objective: To evaluate the efficacy, safety, and cost-effectiveness of a perioperative magnesium (Mg) sulfate protocol in reducing postoperative atrial fibrillation (AF) incidence and ICU resource strain following cardiac surgery.
Methods: Design: Double-blind, single-center randomized controlled trial (RCT). Setting: Tertiary-care academic hospital. Participants: 130 adults undergoing elective cardiac surgery, randomized to Mg sulfate (n=65) or placebo (n=65). Interventions: The Mg group received a pharmacokinetic-guided regimen: 2 g intravenous bolus post-cardiopulmonary bypass, followed by 1 g/h infusion for 5 hours, then 200 mg/h for 19 hours, and oral supplementation (I g every 8 hours) for one week post-discharge. The placebo group received equivalent saline infusions and oral placebo.
Results: Primary outcome: AF incidence was 18.5% in the Mg group vs. 41.5% in placebo (unadjusted RR=0.45, 95% CI: 0.25–0.81; p=0.007). Secondary outcomes: Mg shortened ICU stay by 1.4 days (p<0.001), reduced mechanical ventilation duration by 3.2 hours (p<0.001), and demonstrated comparable safety profiles for hypotension and renal impairment. Subgroup analysis: CABG patients showed 65% risk reduction (OR=0.35, p=0.01). Cost-effectiveness: ICU stay reduction projected $3,500 savings per patient.
Conclusions: Perioperative Mg sulfate significantly reduces AF incidence, accelerates recovery, and lowers healthcare costs, supporting its integration into standardized postoperative protocols. This trial provides Level I evidence for Mg as a guideline-recommended intervention. These findings are promising and support the integration of Mg into standardized postoperative protocols; however, they require confirmation in larger, multicenter studies.

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Materials of care: Engineering the future of the ICU

Diana Portan1,2,3

1 Department of Chemical Engineering, University of Patras, Patras, Greece
2 Department of Mechanical Engineering, Liaoning University of Technology, Jinzhou, China
3 Scientific Research and Technological Development Unit, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Targu Mures, Romania

DOI: 10.2478/jccm-2025-0049

In critical care, the line separating biology from technology is diminishing with progress. Organs that were once deemed beyond repair can now be supported, substituted, or even encouraged to heal. Artificial support is enabled through advanced materials and emerging technologies designed to imitate or enhance living tissue and function. This combination of organs and materials goes beyond mere mechanics; it signifies a profound merging of physiological principles and material design. As we improve these interfaces, the challenge lies in ensuring that innovation not only fulfils the need for survival but also upholds the integrity of the human body it aims to protect.
Initially, advanced materials were designed for: durability, resistance, and control [1]. Polymers, alloys, and composites were perfected to withstand impact rather than to support life. Later, they have been redirected toward healing, and for the ‘dialogue’ with living systems. Due to this shift, the use of technologies and advanced materials in critical care is revolutionizing patient care, enhancing diagnosis, treatment and safety [2]. Redefining the original goals of materials research, from protection to healing, has opened new paths for progress driven by purpose. Today, the development of advanced materials for health and well-being demands a truly multidisciplinary approach. In some intensive care units, engineers and clinicians already work side by side, translating laboratory discoveries into lifesaving technologies. This collaboration recalls an earlier vision of science as a unified endeavour, where boundaries between disciplines dissolve, and the pursuit of understanding becomes the shared gold standard. [More]

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Epidemiological insights into carbapenem resistant infections in critical care settings: A molecular and clinical investigation

Camelia Vintila1, Razvan Lucian Coseriu1, Alexandru Andrei Ujlaki Nagi2, Adrian Man1

1 George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
2 Mures County Clinical Hospital, Targu Mures, Romania

DOI: 10.2478/jccm-2025-0048

Objective: This study aimed to investigate the prevalence and genetic relatedness of multidrug-resistant Gram-negative bacilli, particularly those resistant to carbapenems, in patients admitted to intensive care units. It also sought to explore associations between bacterial colonization or infection and clinical outcomes, including comorbidities, treatment regimens, and mortality.
Methods: Between November 2022 and December 2023, screening and pathological samples were collected from patients at a tertiary hospital. Screening samples included rectal and pharyngeal swabs, while pathological samples comprised respiratory tract secretions. Bacterial identification and antibiotic susceptibility testing were performed using standard microbiological methods. Genetic similarity among isolates was assessed using a molecular fingerprinting technique to detect potential clonal spread.
Results: A total of 62 carbapenem-resistant strains were identified, with Acinetobacter baumannii and Klebsiella pneumoniae being the most prevalent. Pathological isolates exhibited higher resistance levels than screening isolates. Most patients had multiple comorbidities, with cardiac, renal, and pulmonary conditions being the most common. A significant association was found between prolonged intensive care unit stay and increased mortality. However, no significant correlation was observed between the number of comorbidities or antibiotic classes used and mortality. Molecular analysis revealed clonal clusters of Acinetobacter and Klebsiella strains, suggesting nosocomial transmission.
Conclusions: The findings underscore the importance of early screening, molecular surveillance, and stringent infection control measures in intensive care settings.

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Impact of protein intervention timings on critically ill patients: A systematic review and meta- analysis

Pranav Kumar Sharma1, Sanjiya Arora2, Tirth Bhavsar3, Mamta Kamboj4, Rahul Kamboj5, Varnika Gupta6, Anitha Sigamani Ramamurthi7, Kumari Uthayakumar8, Ajay Singh9, Sachin Mahendrakumar Chaudhary10, Arghadip Das11, Arianisa Bajrami12, Sumesh Singh13, Devendra Tripathi14

1 Department of Internal Medicine, Lake Cumberland Regional Hospital, Somerset, Kentucky, USA
2 Department of Internal Medicine, Rohilkhand Medical College, Bareilly, Uttar Pradesh, India
3 Department of Internal Medicine, Smt. NHL Municipal Medical College, Ahmedabad, Gujarat, India
4 Department of Internal Medicine, Government Medical College, Patiala, Punjab, India
5 Department of Internal Medicine, King George’s Medical College, Lucknow, Uttar Pradesh, India
6 Department of Internal Medicine, Lala Lajpat Rai Memorial Medical College, Uttar Pradesh, India
7 Department of Internal Medicine, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
8 Department of Internal medicine, Nanjing Medical University, Nanjing, China
9 Department of Internal Medicine, Sri Ram Murti Smarak Institute of Medical Sciences, Bareilly, Uttar Pradesh, India
10 Department of Internal Medicine, Gujarat Cancer Society Medical College, Hospital and Research Center, Ahmedabad, Gujarat, India
11 Department of Internal Medicine, Nilratan Sircar Medical College and Hospital, Kolkata, West Bengal, India
12 Department of Internal Medicine, University of Tirana, Albania
13 Department of Internal Medicine, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
14 Department of Internal Medicine, Nazareth Hospital, Philadelphia, PA. USA

DOI: 10.2478/jccm-2025-0047

Background: Critically ill patients experience metabolic alterations that promote muscle atrophy and protein catabolism, increasing morbidity and mortality. While adequate protein provision is essential, the optimal timing remains controversial. Guidelines recommend higher protein targets, but evidence from randomized controlled trials is limited and inconsistent.
Aim: To evaluate the effects of early versus late protein supplementation on mortality, complications, and clinical outcomes in critically ill patients.
Methods: A systematic review and meta-analysis were conducted using PubMed, Embase, Cochrane Library, and Google Scholar (January 2010–December 2022). Studies comparing early and late protein administration in adult ICU patients were included. Primary outcomes were mortality, infectious complications, overall complications, pneumonia, ICU/hospital length of stay, and mechanical ventilation duration.
Results: Thirteen studies (8 RCTs, 3 retrospective, 2 prospective cohorts) involving 10,672 patients were analyzed. Mortality (RR = 0.87, 95% CI: 0.74–1.04, p = 0.11; I² = 36%), overall complications (RR = 0.87, 95% CI: 0.74–1.02, p = 0.08; I² = 26%), infectious complications (RR = 0.86, 95% CI: 0.58–1.27, p = 0.37; I² = 65%), and pneumonia (RR = 0.78, 95% CI: 0.41–1.48, p = 0.34; I² = 0%) showed no significant differences between early protein (EP) and late protein (LP) groups. EP significantly reduced ICU length of stay (MD = –0.28 days, 95% CI: –0.33 to –0.23, p < 0.00001; I² = 99%) and mechanical ventilation duration (MD = –0.66 days, 95% CI: –0.90 to –0.41, p < 0.00001; I² = 85%), but was associated with a longer hospital stay (MD = 0.47 days, 95% CI: 0.31–0.63, p < 0.00001; I² = 98%).
Conclusion: Early protein supplementation does not significantly affect mortality or major complications but may shorten ICU stay and ventilation duration. High heterogeneity for some outcomes warrants cautious interpretation.

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