Category Archives: Current

Decisions, outcomes, and learning from what didn’t go wrong

Razvan Azamfirei

Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA

DOI: 10.2478/jccm-2026-0019

We learn from outcomes, yet outcomes are unreliable teachers. In critical care, decisions are made with incomplete information, under time pressure, within systems that normalize workarounds, and where causality is opaque [1]. The feedback we receive later, whether a patient survives or dies or the extent of their recovery, reflects more than the decision itself. Physiology, system redundancies, timely intervention by a colleague, stochastic variance: all shape outcomes independently of our reasoning [2]. If we treat outcomes as verdicts on decision quality, we will systematically mislearn. [More]

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Inhaled sevoflurane in critically ill COVID-19 patients: A retrospective cohort study

Jose J. Zaragoza1, Marco A. Baez-Garcia2,3, Jose M. Lomeli-Teran2,4, Daniela Anzures-Diaz2, Paola Zamudio-Cantellano2,4, Job H. Rodriguez-Guillen2,4

1 Hospital H+ Queretaro, Santiago de Querétaro, Mexico
2 Critical Care Department, Hospital H+ Queretaro, Queretaro, Mexico
3 Universidad Anahuac Queretaro, Queretaro, Mexico
4 Colegio Mexicano de Medicina Crítica, Benito Juárez, Mexico

DOI: 10.2478/jccm-2026-0011

Background: Managing sedation in critically ill COVID-19 patients is challenging due to high sedative requirements and organ dysfunction that alters drug metabolism. Inhaled sevoflurane offers a lung-eliminated alternative that may mitigate drug accumulation.
Methods: This single-center, retrospective cohort study analyzed 43 mechanically ventilated COVID-19 patients (March–November 2020). Patients received inhaled sevoflurane adjunctive to IV sedation (n=30) or IV sedation alone (n=13). The primary outcome was the cumulative dose of IV sedatives over 7 days. Secondary outcomes included time to extubation and antipsychotic use.
Results: There was no significant difference in the cumulative dose of IV sedatives between groups. However, the sevoflurane group had a significantly longer median duration of mechanical ventilation (206 [IQR 144-356] vs 144 [IQR 115-156] hours, p=0.005) and a higher requirement for antipsychotic medication (66.6% vs 15.3%, OR 18.6, p=0.011). Daily doses of propofol were lower in the sevoflurane group on specific days, but overall burden was unchanged.
Conclusions: In this cohort, adjunctive inhaled sevoflurane did not significantly reduce the cumulative burden of IV sedatives and was associated with delayed extubation and increased antipsychotic use. While sevoflurane is a feasible alternative, these findings suggest caution regarding weaning and delirium management in COVID-19 patients.

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Bimodal distribution of trauma-related acute kidney injury (TrAKI): A clinical review

Eleni Sertaridou1, Christina Alexopoulou2, Vasilios Papaioannou2

1 ICU Department, University Hospital of Alexandroupolis, Alexandroupolis, Greece
2 Medical School, Democritus University of Trace; ICU Department, University Hospital of Alexandroupolis, Alexandroupolis, Greece

DOI: 10.2478/jccm-2026-0009

Severe trauma remains the leading cause of mortality and disability among young adults. Trauma-related Acute Kidney Injury (TrAKI) has been associated with worse outcomes, increased healthcare costs, and higher morbidity among survivors. The review aims to evaluate, from a pathophysiological perspective, the risk factors for TrAKI at different time points of trauma treatment, highlighting the need for early diagnosis of the syndrome and the implementation of preventive measures.
TrAKI is triggered at the time the injury occurs and further worsened by factors related to resuscitation process and potential complications. Severe trauma, due to hemorrhagic shock, is considered to act as the first hit. All subsequent necessary lifesaving procedures applied in trauma management, such as fluid resuscitation, massive transfusion and emergency surgery, could act as second hit, triggering “early” TrAKI, within 24-72 hours, due to renal hypoperfusion, hypoxia and reperfusion injury (R/I). The following critical care treatment, seems to act as the final third hit, resulting in “late” TrAKI appeared in 5-7 days or even later, caused by distal complications.
The incidence of TrAKI shows a biphasic pattern, with an “early “peak within 2-3 days after trauma, and a “delayed” occurring a week or later. This distinction could be of clinical importance because of its disparate pathophysiology and outcome. Early recognition of risk factors and diagnosis of TrAKI could improve the application of preventive measures and therapeutic treatment, reducing its prevalence.

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Impaired peripheral mononuclear cell metabolism in patients at risk of developing sepsis: A cohort study

Velma Herwanto1,2, Ya Wang2, Maryam Shojaei2, Alamgir Khan3, Kevin Lai4, Amith Shetty4, Stephen Huang2, Tracy Chew5, Sally Teoh2, Marek Nalos2, Mandira Chakraborty2, Anthony S McLean2, Benjamin M P Tang2

1 Universitas Tarumanagara, Faculty of Medicine, Jakarta, Indonesia
2 Department of Intensive Care Medicine, Nepean Hospital, Kingswood, NSW, Australia
3 Australian Proteome Analysis Facility, Macquarie University, NSW, Australia
4 Department of Emergency Medicine, Westmead Hospital, NSW, Australia
5 Sydney Informatics Hub, The University of Sydney, NSW, Australia

DOI: 10.2478/jccm-2026-0010

Introduction: Dysregulated immune responses are central to progression of sepsis and closely associated with impaired cellular metabolism. However, most existing studies have focused on late-stage sepsis, leaving metabolic alterations during earlier stages of infection poorly characterised. This study aimed to determine whether immune cell metabolic impairment is already present during uncomplicated infection, prior to the development of sepsis, and to evaluate its potential as an early indicator of immune dysfunction and risk of progression.
Materials and methods: Forty patients with sepsis (fulfilling Sepsis-3 criteria) and 27 patients with uncomplicated infection were recruited from the emergency department along with 20 healthy volunteers. Whole blood samples were collected to assess gene expression, cytokine levels, and cellular metabolic functions, including mitochondrial respiration, oxidative stress, and apoptosis in immune cells.
Results: Mitochondrial respiration was significantly impaired in immune cells from both uncomplicated infection and sepsis patients compared with healthy controls (p < 0.05), with more pronounced impairment in established sepsis. Downregulation of BCL2 and BBC3 gene expression was observed in sepsis patients (p < 0.05), but not in uncomplicated infection, potentially contributing to differences in the severity of metabolic impairment. Impaired mitochondrial respiration was significantly associated with increased mitochondrial oxidative stress (p < 0.05), which was elevated in uncomplicated infection and further increased in sepsis. Oxidative stress levels also correlated with tumour necrosis factor-α (r = 0.330) and the expression of CYCS, TP53, SLC25A24, and TSPO (rs = −0.4926, −0.4422, 0.4382, and 0.4835, respectively). Despite these metabolic alterations, no significant differences in immune cell apoptosis were observed between uncomplicated infection and sepsis patients.
Conclusions: Immune cell metabolic dysfunction is present in patients with uncomplicated infection before the clinical onset of sepsis. Early mitochondrial dysfunction and oxidative stress may represent promising targets for further investigation as early biomarkers of immune dysfunction and sepsis risk.

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Non-thyroidal illness (euthyroid sick) syndrome: Laboratory aspects and clinical significance in critically ill patients and other diseases – A narrative review

Liong Boy Kurniawan

Department of Clinical Pathology, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia

DOI: 10.2478/jccm-2026-0008

Formerly termed euthyroid sick syndrome, non-thyroidal sickness syndrome (NTIS) is a disorder that frequently occurs in acute or chronic illnesses that alter the levels of thyroid hormone and patterns, even in the absence of hypothalamic-pituitary-thyroid axis problems or diseases. The primary findings on the thyroid hormone panel in NTIS are elevated reverse T3 (rT3) and decreased triiodothyronine (T3) levels, which may be followed by other thyroid hormone abnormalities, such as thyroid-stimulating hormone (TSH) and thyroxine (T4). The incidence of NTIS increases among hospitalized patients with critical illness, and there is an associated increase in mortality. NTIS is also associated with worsening outcomes during and after treatment in patients hospitalized with infectious or non-infectious diseases, such as cardiovascular, kidney, lung, diabetes mellitus, autoimmune, and other diseases. In patients with critical illnesses admitted to the Intensive Care Unit (ICU), serial examination of a panel of thyroid function tests, including T3 and rT3, is necessary to estimate the phase of the disease (whether acute, chronic, or recovery) and can be used to predict the risk of mortality during treatment.

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Late complications of the Rastelli procedure – infective endocarditis and homograft stenosis: A case report

Elena-Andreea Sava1, Ilie-Marius Ciorba2,3, Claudiu-Ionut Sântean1, Andrei Manea4,5, Nicoleta-Maria Crăciun-Ciorba6,7

1 Department of Cardiology, Targu Mures Institute for Cardiovascular Diseases and Heart Transplantation, Targu Mures, Romania
2 Department of Internal Medicine I, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
3 Department of Gastroenterology, Emergency County Hospital Targu-Mures, Targu Mures, Romania
4 Doctoral School of Medicine and Pharmacy, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
5 Department of Radiology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
6 Department of Internal Medicine II, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
7 Department of Internal Medicine I, Emergency County Hospital Targu-Mures, Targu Mures, Romania

DOI: 10.2478/jccm-2026-0007

Introduction: Advances in surgical techniques have significantly improved the prognosis of patients with operated congenital heart malformations. However, late complications pose a challenge to therapeutic management. Although the Rastelli procedure has brought substantial benefits in the surgical correction of transposition of the great arteries in pediatric patients, it carries the burden of numerous complications into adulthood.
Case presentation: We present the case of a 35-year-old man diagnosed at birth with D-transposition of the great arteries, atrial septal defect, ventricular septal defect and severe pulmonary stenosis. His medical history revealed two previous operations: a Blalock-Taussing shunt at the age of 4 months and a Rastelli procedure at the age of 3 years. The patient presented to the emergency room with fever and congestive heart failure symptoms. Subsequent investigations revealed two late complications of the Rastelli procedure: stenosis of the homograft connecting the pulmonary artery to the right ventricle and infective endocarditis.
Conclusions: Although the clinical context may lead to the assumption that this is a case of congestive heart failure due to homograft stenosis, we must not overlook the possibility of overlapping infective endocarditis, which may also contribute to the development of heart failure.

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Real-world clinical decision of andexanet alfa administration for intracranial hemorrhage during anticoagulant therapy using factor Xa inhibitor

Shigeo Yamashiro1, Keisuke Harada1, Shunsuke Izumi1, Yusuke Morikawa1, Tomoko Ikemoto1, Koki Kameno1, Tomoaki Goto1, Yuki Ohmori1, Masatomo Kaji1, Akitake Mukasa2

1 Division of Neurosurgery, Department of Cerebrovascular Medicine and Surgery, Saiseikai Kumamoto Hospital, Kumamoto, Japan
2 Department of Neurosurgery, Faculty of Life Sciences, Kumamoto University, Kumamoto Japan

DOI: 10.2478/jccm-2025-0046

Introduction: Andexanet alfa shows excellent hemostatic efficacy in treating intracranial hemorrhage (ICH) during Xa inhibitor therapy. However, its optimal use remains uncertain.
Aim of the study: This study aims to evaluate our clinical experience in managing Xa inhibitor-related ICH to clarify its appropriate application.
Material and methods: This study was conducted as an observational, non-interventional study. We observed 63 cases of ICH in patients receiving anticoagulation therapy with apixaban, rivaroxaban, or edoxaban. After excluding 14 patients due to fatal outcomes or complete hemostasis, 49 patients were eligible for andexanet alfa administration.
Results: The mean age and hematoma volume was 78 years and the 35ml, respectively. Based on patient characteristics and severity, andexanet alfa was administered to 23 patients, while 26 patients received usual care. Hemorrhage enlargement was absent in 22 cases (92.8%) in the andexanet group and in 22 cases (84.6%) in the usual care group. Hemorrhage expansion occurred in three cases from the usual care group, one patient undergoing emergency surgery and another died from uncontrollable intraoperative bleeding. Two patients (8.7%) in the andexanet group experienced thromboembolic events as adverse reactions. At 3 months, the modified Rankin Scale (mRS) was 3 or lower in 39% of the andexanet group and 50% of the standard care group.
Conclusions: Although patient selection bias make it difficult to draw definitive conclusions, we recommend considering andexanet alfa administration for cases within several hours of the last Xa inhibitor dose to prevent neurological deterioration. Emergency surgical cases should also be eligible for andexanet alfa to ensure intraoperative safety. Further research is required to determine clinically appropriate indications for its use.

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Veno-venous ECMO for rapidly progressing interstitial lung disease: A multidisciplinary approach

Samreen Tariq, Fiona O’Hannigan, Nizrull Nasir, Serena O’Brien, Brian Marsh, Jennifer Hastings, John Stack, Josephine Kelliher, Katherine O’Reilly

Mater Misericordiae University Hospital, Dublin, Ireland

DOI: 10.2478/jccm-2026-0006

Introduction: This is a unique case of fulminant respiratory failure secondary to a rare cause of rapidly progressing ILD; antisynthetase syndrome (ASS). Failure to deliver timely multi-modal treatment in these cases can lead to increased morbidity and mortality.
Case presentation: A previously healthy 27-year-old male presented to his local hospital with a 1-week history of malaise, shortness of breath and cough. Initial work up including bloods and imaging were suggestive of community acquired multi lobar pneumonia, for which he received treatment as per local guidelines. Unfortunately, despite broad empirical antimicrobial cover, he continued to deteriorate with worsening type-1 respiratory failure requiring intubation and subsequent institution of prone position ventilation. Extensive microbiological investigations yielded no positive results. On day 7 of admission immunological testing revealed an ENA screen positive for Jo-1 antibody and a diagnosis of ASS was made. Despite treatment with immunosuppression the patient’s condition rapidly deteriorated and the decision to support with V-V ECMO was made following MDT consideration as there remained uncertainty as to the extent of reversibility of the underlying condition.
Conclusions: This patient recovered with combination of conventional immunosuppression, therapeutic plasma exchange and ECMO support. This case highlights Antisynthetase syndrome as a cause of reversible interstitial lung disease in the ICU and the importance of multi-disciplinary decision making and aggressive treatment approach in the management of such conditions.

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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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