Category Archives: AoP

High-fidelity simulation programs in ICU-related ethical non-technical skills training: A narrative review

Alexandra-Maria Boldis, Cristina Petrisor, Darius Turcas, George-Calin Dindelegan

Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania

DOI: 10.2478/jccm-2026-0021

Objective: Is there a place for non-technical skills training in the ICU? And what teaching strategy should we implement in this process? This narrative review analyzes the benefits of teaching ethics in the ICU environment by applying high-fidelity simulation scenarios to real-life situations, thereby improving communication, moral reasoning, self-reliance, cooperation, and perceptual skills.
Methods: In the literature, there are few publications on the training of ICU residents in non-technical skills and ethical dilemmas using high-fidelity simulations. After searching and scoping the database, we have identified 8 publications relevant to this narrative review.
Results: In the reviewed studies, the main topics discussed and rehearsed using simulations were as follows: communicating an adverse event during anesthesia in one study [5], delivering bad news in two studies [14,18], the ethics of end-of-life care, and the do-not-resuscitate order in three studies [5,18,19], and ethical non-technical skills such as communications, teamwork and confidence in emergent real-life situations in four studies [15,16,17,20].
Conclusions: Developing a more structured approach to teaching ethics-related events is important, particularly in critical care settings. All reviewed studies reached the same conclusion: high-fidelity simulation training is an educational strategy for ICU residents to develop a foundation in ethical considerations and moral reasoning by improving ethical non-technical skills, such as confidence, communication, teamwork, delivering bad news, and end-of-life care.

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Percutaneous tracheostomy in Costa Rican intensive care units: Multicenter epidemiology, practices, and immediate complications

Pablo Alvarez-Aguilar1, Leonardo Chacón-Prado2, Dennis Rojas-Quirós2, Oscar Palma-Rodríguez1, Donato Salas-Segura2, TRAQUEOSCR Group

1 Hospital México, Caja Costarricense de Seguro Social, San José, Costa Rica
2 Hospital Rafaél Ángel Calderón Guardia, Caja Costarricense de Seguro Social, San José, Costa Rica

DOI: 10.2478/jccm-2026-0020

Introduction: This study describes the epidemiological and clinical profile of ICU patients undergoing percutaneous tracheostomy in Costa Rica and identifies predictors of acute complications, addressing ongoing debates on timing, technique, and risk stratification.
Methods: We performed a prospective multicenter cohort study in eight CCSS hospitals (2019–2022), including adult ICU patients undergoing percutaneous tracheostomy. Demographic, clinical, and procedural data were collected, and multivariable logistic regression identified predictors of complications.
Results: A total of 516 patients were analyzed (mean age 53.2 ± 16.3 years; 68.2% male). The main indications were anticipated prolonged ventilation (32.4%), neurological deficits (26.7%), and ventilation >10 days (21.8%). The Ciaglia and Griggs techniques were used in 51.0% and 48.3% of cases, respectively. Capnography was applied in 74.2%, ultrasound in 17.7%, and bronchoscopy in 3.1%. First-pass success was achieved in 85.1%. Acute complications occurred in 28.3% of patients, predominantly minor bleeding (25.4%), while serious complications (airway loss, false passage, or bleeding requiring surgery) were rare (3.9%). No procedure-related deaths were observed. Independent predictors of complications included anticoagulation (OR 2.82), obesity (OR 2.10), coagulopathy (OR 2.29), prior neck surgery (OR 3.49), cervical immobilization (OR 4.68), and technical difficulty (OR 4.15 for any complication; OR 2.00 for serious complications). Airway management by physicians, compared with respiratory therapists, was also associated with higher risk (OR 1.52).
Conclusions: Percutaneous tracheostomy was feasible in multiple ICUs of the CCSS with complication rates comparable to international cohorts. Risk factors for complications included anticoagulation and prior neck surgery. Wider adoption of adjunctive monitoring tools and structured multidisciplinary training may further enhance procedural safety. These findings should be interpreted in the context of an observational design and a broad definition of complications.

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Comparing length of stay between adult patients admitted to the intensive care unit with alcohol withdrawal syndrome treated with phenobarbital versus lorazepam

Mary C Hoye1, Sorin Danciu1, Marc A Jacobs2, Brad J Glavan2

1 Providence Portland Medical Center, Portland, OR, USA
2 The Oregon Clinic, Portland, OR, USA

DOI: 10.2478/jccm-2026-0018

Objective: Review the use of phenobarbital and lorazepam to treat alcohol withdrawal syndrome (AWS) in the ICU, compare length of stay, examine medication use trends, implement provider training, and evaluate outcomes post-training.
Methods: Design – Retrospective observational study, Quality improvement. Setting – Tertiary care hospital with 36 ICU beds. Patients – Adults admitted to the ICU and placed on clinical institute withdrawal assessment (CIWA) protocol. Patients with epilepsy were excluded.
Results: During the 34-month baseline period, 713 patients were admitted to the ICU with alcohol use disorder (AUD) on CIWA, without epilepsy. 189 patients were treated with phenobarbital, 460 patients received only lorazepam, 64 patients received neither medication. All but 2 of the patients who received phenobarbital also received lorazepam. Compared to phenobarbital, lorazepam-only patients had shorter ICU LOS (p<0.001, 95% CI -2.36, -1.32) but higher mortality 13.91% vs. 4.76% (p=0.0008). We then developed and provided a training (which we refer to as an “intervention”) to all ICU providers encouraging consistent use of phenobarbital in the ICU when appropriate. During the 3-month post-intervention period 44 patients were admitted to the ICU with AUD on CIWA protocol. Of the 44 patients: 26 received phenobarbital, 12 received only lorazepam, 6 received neither medication. Significantly more patients were treated with only phenobarbital (57.69%)) compared to baseline (1.06%). Compared to patients treated with phenobarbital, patients treated with only lorazepam had a significantly higher mortality rate (33.33% vs. 7.69%, p=0.04).
Conclusions: We found significant variability in the use of phenobarbital and lorazepam for treatment of AWS in the ICU. After a quality improvement training for ICU physicians, there was less frequent concurrent use of benzodiazepines and barbiturates, no difference in ICU or hospital LOS, and significantly lower mortality rate for those treated with phenobarbital.

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Influence of different short peripheral cannula materials on the incidence of phlebitis in intensive care units: A post-hoc analysis of the AMOR-VENUS study

Yutaro Shinzato1, Hideto Yasuda1-3, Haruka Taira1, Yuki Kishihara1, Masahiro Kashiura1, Takashi Moriya1, Yuki Kotani4, Natsuki Kondo5, Kosuke Sekine6, Nobuaki Shime6, Keita Morikane7

1 Jichi Medical University Saitama Medical Center, Saitama, Japan
2 Alliance for Vascular Access Teaching and Research, Griffith University, Nathan, Queensland, Australia.
3 Department of Clinical Research Education and Training Unit, Keio University Hospital Clinical and Translational Research Centre (CTR), Tokyo, Japan.
4 Kameda Medical Center, Kamogawa, Japan
5 Chiba Emergency and Psychiatric Medical Center, Chiba, Japan
6 Division of Clinical Laboratory and Infectious Diseases, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
7 Yamagata University Hospital, Yamagata, Japan

DOI: 10.2478/jccm-2026-0014

Aim of the study: Short peripheral cannula (SPC)-related phlebitis occurs in 7.5% of critically ill patients, and mechanical irritation from cannula materials is a risk factor. Softer polyurethane cannulas reportedly reduce phlebitis, but the incidence of phlebitis may vary depending on the type of polyurethane. Differences in cannula stiffness may also affect the incidence of phlebitis; however, this relationship is not well understood. This study analyzed intensive care unit (ICU) patient data to compare the incidence of phlebitis across different cannula products, focusing on polyurethane.
Material and Methods: This is a post-hoc analysis of the AMOR-VENUS study that involved 23 ICUs in Japan. We included patients aged ≥ 18 years, who were admitted to the ICU with SPCs. The primary outcome was phlebitis, evaluated using hazard ratios (HRs) and 95% confidence intervals (CIs). Based on the market share and differences in synthesis, polyurethanes were categorized into PEU-Vialon® (BD, USA), SuperCath® (Medikit, Japan), and other polyurethanes; non-polyurethane materials were also analyzed. Multivariable marginal Cox regression analysis was performed using other polyurethanes as a reference.
Results: In total, 1,355 patients and 3,429 SPCs were evaluated. Among polyurethane cannulas, 1,087 (33.5%) were PEU-Vialon®, 702 (21.6%) were SuperCath®, and 276 (8.5%) were other polyurethanes. Among non-polyurethane cannulas, 1,292 (39.8%) were ethylene tetrafluoroethylene (ETFE) cannulas, and 72 (2.2%) used other materials. The highest incidence of phlebitis was observed with SuperCath® (13.1%). Multivariate analysis revealed an HR of 1.45 (95% CI 0.75-2.8, p = 0.21) for PEU-Vialon®, 2.60 (95% CI 1.35-5.00, p < 0.01) for SuperCath®, 2.29 (95% CI 1.19-4.42, p = 0.01) for ETFE, and 2.2 (95% CI 0.46-10.59, p = 0.32) for others.
Conclusions: The incidence of phlebitis varied among polyurethane cannulas. Further research is warranted to determine the causes of these differences.

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Prediction of acute kidney injury in mechanically ventilated patients with COVID-19-related septic shock: An exploratory analysis of non-renal organ dysfunction markers

Jose J. Zaragoza1, Jonathan S. Chávez-Iñiguez2,3, Armando Vazquez-Rangel4

1 Critical Care Department, Hospital H+ Queretaro, Mexico
2 Nephrology Department, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico
3 Centro Uniersitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Mexico
4 Nephrology Department, Instituto Nacional de Cardiologia, Mexico City, Mexico

DOI: 10.2478/jccm-2026-0013

Background: Acute kidney injury (AKI) is a common and serious complication in critically ill patients with non-kidney organ dysfunction. Early prediction of AKI is crucial for timely intervention and improved outcomes. This study aimed to identify readily available non-renal predictors of AKI and to develop an exploratory prediction model in a specific cohort of critically ill patients with COVID-19-related septic shock requiring mechanical ventilation.
Materials and methods: This was a single-center, observational, retrospective cohort study conducted in the respiratory ICU of Hospital H+ Querétaro between April and December 2020. The study included 42 mechanically ventilated patients with septic shock secondary to SARS-CoV-2 infection and non-kidney organ dysfunction. AKI was defined using the KDIGO criteria. Trend analysis, bivariate and multivariate linear regression, were used to identify predictors of AKI and severe AKI.
Results: AKI occurred in 23 (54.8%) patients, with 6 (14.3%) developing severe AKI. Trend analysis revealed differences in norepinephrine dose, hemoglobin, and lactate trends between groups. A simplified logistic regression model, validated internally with bootstrapping to prevent overfitting, identified a protective trend associated with higher hemoglobin levels on admission. Quantitative analysis of a forecasting model for daily renal function showed moderate predictive accuracy.
Conclusions: This study identified several readily available non-kidney organ dysfunction variables that can predict AKI and its severity in critically ill patients with COVID-19-related septic shock. These findings may help in the early identification of at-risk patients and facilitate timely interventions to potentially improve outcomes. Further validation in larger and more diverse populations is warranted.

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Efficacy of gabapentin versus trospium chloride for prevention of catheter-related bladder discomfort inside the surgical intensive care unit: A prospective, randomised, controlled clinical study

Ahmed Moustafa Mohamed, Wessam Zaher Selima

Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt

DOI: 10.2478/jccm-2026-0015

Introduction: Catheter-related bladder discomfort (CRBD) after perioperative catheterisation of the urinary bladder (COUB) is not uncommon.
Aim of the study: We evaluated the efficacy of both oral gabapentin and trospium in preventing CRBD during the early postoperative period in patients admitted to the surgical intensive care unit (S-ICU).
Material and Methods: 120 patients aged 20–65 years, ASA I, II or III who were admitted to S-ICU after undergoing elective spinal surgery (ESS) with COUB were included. They were randomly assigned to be administered either an oral 400 mg gabapentin capsule (Group G) or an oral 60 mg slow-release trospium chloride capsule (Group T) or nothing (Group C). The primary goal was the occurrence of CRBD and its severity at 1, 2, 6, 12, and 24 hours after the study drug administration (SDA).
Results: Group G and group T had a statistically significant lower incidence of CRBD than group C at 1, 2, 6, 12, and 24 hours after SDA, respectively. Both had considerably lower severity than group C in the first two hours only (P= 0.001 and 0.001, respectively). Group T had non-significantly lower incidence and severity of CRBD than group G. Group G had significantly lower mean total fentanyl requirements for up to 24 hours after SDA than group T and group C (P < 0.001).
Conclusion: Both oral gabapentin capsules and slow release trospium chloride capsules administered postoperatively, significantly decreased both the incidence of CRBD and its severity in the early postoperative period amongst S-ICU patients, without significant differences between the two drugs.

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Positive fluid balance is associated with earlier acute kidney injury in COVID-19 patients

Rezwan Munshi1, Sandra Gomez-Paz2, Salman Bhutta3, Joshua Fogel4, James Pellegrini1, Narois Nehru1, Eric Lam5, Sofia Rubinstein1

1 Nassau University Medical Center, East Meadow, NY, USA
2 Brody School of Medicine, East Carolina University, Greenville, NC, USA
3 Northwell Health, New Hyde Park, NY, USA
4 Brooklyn College, Brooklyn, NY, USA
5 Rutgers New Jersey Medical School, Newark, NJ, USA

DOI: 10.2478/jccm-2026-0016

Introduction: Managing fluid balance in COVID-19 patients can be challenging, particularly if acute kidney injury (AKI) develops.
Aim of the study: We study the relationship between fluid net input and output (FNIO) in COVID-19 patients with development of AKI, time to development of AKI, in-hospital length of stay (LOS), and in-hospital mortality.
Material and Methods: Retrospective study of 403 patients with COVID-19. Data for FNIO were from day 1 through day 10 or earlier if AKI occurred.
Results: AKI occurred in 22.8%, in-hospital mortality occurred in 26.3%, mean days to AKI were 7.7 (SD=6.3), and mean LOS was 11.5 (SD=13.2) days. In the multivariate logistic regression analyses, increased FNIO mean was significantly associated with slightly increased odds for mortality (OR=1.001, 95% CI:1.0001, 1.0011, p=0.02) but was not significantly associated with AKI. In the multivariate linear regression analyses, increased FNIO mean was significantly associated with lesser days to AKI (B=-6.63*10-5, SE=<0.001, p=0.003) in the whole sample, greater days to AKI in the subset of those with ICU treatment (B=<0.001, SE=<0.001, p<0.001), while FNIO mean was not significantly associated with LOS.
Conclusions: Positive fluid balance was associated with faster onset of AKI and increased mortality. Fluid administration in patients with COVID-19 should be guided by routinely measuring FNIO. A restrictive fluid management regimen rather than usual care should be practiced.

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Admission biomarkers and COVID-19 mortality: A retrospective study during Vietnam’s pandemic peak

Uyen Thi Bich Nguyen1, Hau Phuc Le2,3, Vu Hoang Anh Nguyen4, Ai-Thanh Tran-Nguyen4,5

1 Department of Nephrology and Hemodialysis, Le Van Viet Hospital, Ho Chi Minh City, Vietnam
2 Outpatient Clinic for HIV-AIDS Patients, Chau Thanh District Medical Center, Tra Vinh Province, Vietnam
3 Can Tho University of Medicine and Pharmacy, Can Tho, Vietnam
4 Department of Psychosomatic Medicine, Thu Duc City Hospital, Ho Chi Minh City, Vietnam
5 Thu Duc City Hospital, Ho Chi Minh City, Vietnam

DOI: 10.2478/jccm-2026-0012

Background: This study aimed to evaluate the prognostic value of key admission biomarkers in predicting mortality among hospitalized COVID-19 patients and to establish optimal cut-off thresholds for clinical decision-making.
Methods: Retrospective cohort study included 269 COVID-19 patients treated at Thu Duc City Hospital, Vietnam, during the peak of the fourth pandemic wave in 2021. Logistic regression identified independent predictors of mortality, and receiver operating characteristic (ROC) curve analysis assessed the diagnostic performance of biomarkers. The area under the ROC curve (AUROC), Sensitivity, Specificity and Accuracy Index were used to determine optimal cut-off values.
Results: Among the 269 patients, 53 (19.7%) died and 216 (80.3%) survived. Non-survivors exhibited elevated D-dimer (4.48 μg/mL vs 0.93 μg/mL, p < 0.0001), neutrophil counts (6.8 × 10⁹/L vs 3.5 × 10⁹/L, p < 0.0001) and white blood cell counts (11.68 × 10⁹/L vs. 7.87 × 10⁹/L, p < 0.0001). Lymphocyte counts and fibrinogen levels were significantly lower in non-survivors (p < 0.05). Logistic regression identified D-dimer (OR = 1.05, 95% CI: 1.02–1.09, p = 0.001), neutrophil counts (OR = 1.32, 95% CI: 1.10–1.63, p = 0.005) and lymphocyte counts (OR = 0.51, 95% CI: 0.26–0.92, p = 0.033) as significant predictors of mortality. ROC analysis revealed that D-dimer (AUROC = 0.809) and neutrophil counts (AUROC = 0.726) demonstrated strong discriminatory power, with cut-off values of ≥1.126 μg/mL (sensitivity = 90.57%, specificity = 60.19%) and ≥6.715 × 10⁹/L (sensitivity = 52.83%, specificity = 82.87%), respectively.
Conclusion: These findings support the use of admission biomarkers to guide early interventions and improve patient outcomes in severe COVID-19 cases. Further studies are warranted to validate these results and explore their applicability in other settings.

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