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Assessing volume status in heart failure: The role of renal duplex ultrasound in evaluating cardiorenal morbidity and heart failure mortality

Mohamed Elsayed Elrokh, Waleed Shehata Hassan, Ramadan Ahmed Khalil, Ayman Nehad Moharam, Emad Eldin Omar Abdelaziz

Department of Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt

DOI: 10.2478/jccm-2025-0029

Background: Critical care physicians face challenges managing decompensated heart failure. This study aims to examine the volume status of patients with decompensated heart failure and evaluate the effectiveness of the renal resistive index (RRI) and renal venous flow pattern (VFP) in assessing volume status and predicting outcomes related to cardiorenal syndrome and mortality.
Patients and methods: This prospective study was conducted in the intensive care unit of Kasr Elainy Hospital at Cairo University with patients admitted for acute decompensated heart failure (ADHF). Patients were subjected to clinical screening, laboratory measurements, and echocardiographic examination, including cardiac index renal duplex.
Results: This study included 61 patients with a mean age of 64.8±9.1 years. Renal duplex parameters were 0.692±0.087 for the mean RRI, and the percentages of VFP were as follows: continuous 49.2%, biphasic 27.9%, and monophasic 23%. Elevated proBNP levels and IVC collapsibility index were significantly associated with RRI ≥0.75 and abnormal VFP patterns in assessing volume status. The ROC curve of the RRI, VFP, proBNP, SOFA score, ADHERE risk score, and GWTG-HF score for AKI occurrence showed that RRI has 68% sensitivity to detect AKI, but VFP has better results with 86.4% sensitivity. RRI has a prognostic role in predicting in-hospital mortality in acute heart failure, as RRI has 83.3% sensitivity, and VFP showed better results with 83.3% sensitivity. Also, VFP had a better predictive value for the incidence of 3 months mortality with 90.9% sensitivity, while RRI has 63.4% sensitivity.
Conclusion: Renal duplex measures, such as VFP and RRI, are highly effective prognostic tools for identifying worsening renal function. Beyond renal outcomes, these measures also serve as reliable predictors of mortality and survival in patients with acute decompensated heart failure, offering clinicians the opportunity to tailor therapeutic approaches early during treatment.

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Comparative analysis of outcomes between anemic and non-anemic critically ill elderly patients in a geriatric ICU in Egypt: A focused study

Manar Mamdouh Abd Al Kader, Manar Mostafa Adel Maamoun, Walaa W. Aly, Heba Youssif Youssif, Mennatallah Safwat Elaraby

Geriatrics and Gerontology Department, Faculty of Medicine, Ain Shams University

DOI: 10.2478/jccm-2025-0028

Background: Numbers of elderly patients who are being admitted to the intensive care unit (ICU) are increasing; Among ICU patients, elderly patients represent a particular subgroup, with a proportion of up to 50% for patients aged 65 years and over, and on average about 35% of admissions for patients older than 70–75 years. Also, those aged 80 years and older represent around 15% of total ICU population. In Egypt, a study conducted in seven regions found that geriatric patients represent around 48.5% of total ICU admission. Elderly individuals are more susceptible to anemia due to multiple comorbidities and age related changes. Anemia is a common problem among critically ill elderly patients with serious consequences. It is recognized as an independent risk factor for increased mortality and morbidity. In fact, anemia is the most prevalent hematologic disorder in the ICU. The prevalence of anemia among critically ill patients admitted to the ICU ranges from 60 to 66%. Approximately 60% of critically ill patients are anemic at admission, and an additional 40–50% develop anemia during their ICU stay. The condition is particularly common among older patients. Low hemoglobin (Hb) concentrations are associated with prolonged ICU and hospital stays , as well as increased mortality rates. Therefore, anemia is consequently a significant public health issue from the medical and economic perspectives. Aim: To compare outcomes between anemic and non- anemic critically ill elderly patients admitted to the Geriatric ICU at Ahmed Shawky geriatric Hospital, Ain Shams University hospitals.
Subjects and methods: A Prospective cohort study was conducted on two hundred sixteen elderly patients of both sexes aged 60 years old or older. It was carried out in the geriatric ICU at Ahmed Shawky geriatric Hospital, Ain Shams University Hospitals. Data collection included participants demographics, medical history, full labs assessment and anemia evaluation based on hemoglobin level, Severity of illness was assessed by validated scoring systems, including the Sequential organ failure assessment (SOFA score) on the first day of admission, as well as Acute physiology and chronic Health Evaluation (APACHE II, APACHE IV). Additionally, the Mortality Probability Model Score (MPM0-III) was applied at first day of admission, 48hours and 72 hours following ICU admission. Anemia management strategies were documented, including the use of blood transfusions, iron therapy and other supportive treatments. Clinical outcomes assessed included ICU length of stay, Site of discharge, in- hospital Mortality and the incidence of Hospital acquired infections.
Results: On admission 172(79.6%) of studied subjects were anemic, (90)41.7% had mild anemia, 56(25.9%) had moderate anemia and 26(12%) had severe anemia. Anemic patients showed significantly higher SOFA, MPM 24hrs, MPM 48hrs, MPM 72hrs, APACHE4, SAPSIII, extended hospital stays, and increased rates of hospital acquired infections(P<0.05). Predicators of mortality included the severity of anemia, the need for mechanical ventilation, and thrombocytopenia (P<0.001). However, anemia on admission to ICU was not a direct predictor of in- hospital mortality. Regarding management of anemia: seventy three (33.9%) of the anemic subjects received blood transfusion. Fourteen (6.5%) received either enteral or parental iron therapy, 20(9.3%) of studied subjects were given erythropoietin, 3(1.4%) of them were given vitamin B12 and folic acid.
Conclusion: On admission, 79.6% of critically ill elderly patients had anemia. The presence of anemia in this population was associated with prolonged ICU stays, increased in-hospital mortality and a higher risk of hospital acquired infections.

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Refractory metabolic acidosis and acute abdominal compartment syndrome following Holmium Laser Enucleation of Prostate (HoLEP)

Murugananth Nithiyananthan1, Shitalkumar Sharad Shah1, Aarthi Suhitharan2, Suhitharan Thangavelautham1

1 Singapore General Hospital, Singapore, Singapore
2 National Junior College, Singapore, Singapore

DOI: 10.2478/jccm-2025-0027

Introduction: Holmium Laser Enucleation of the Prostate (HoLEP) is a widely used minimally invasive surgical technique for benign prostatic hyperplasia (BPH), offering advantages such as reduced bleeding, shorter hospitalization, and elimination of TURP syndrome. However, complications related to fluid absorption and capsular perforation can still occur. We report a rare case of severe refractory metabolic acidosis and acute abdominal compartment syndrome (ACS) following HoLEP.
Case Presentation: A 74-year-old male with diabetes and hypertension underwent HoLEP for a 180-ml prostate, during which 106 liters of normal saline irrigation were used over three hours. Intraoperatively, the patient developed sudden respiratory distress and hypotension, with arterial blood gas analysis revealing severe metabolic acidosis (pH 7.141, HCO₃ 11 mEq/L, Cl 115 mEq/L), primarily due to excessive saline absorption and hyperchloremia. The patient required intubation, vasopressor support, and emergency dialysis due to worsening hemodynamic instability. Postoperative imaging revealed intra-abdominal fluid collection, which was drained percutaneously. After two days of intensive ICU management, the acidosis resolved, and the patient was successfully extubated.
Conclusion: This is the first case highlighting the potential risks of normal saline absorption and the effect of capsular perforation, which caused ACS and refractory acidosis, and required CRRT due to the prolonged duration of HoLEP.

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Hyperglycemia, diabetes, and de novo diabetes in patients hospitalized in intensive care units for COVID-19 in Colombia: Results from a longitudinal cohort study

John Jaime Sprockel1,2, Ana Maria Perez2, Maria Camila Chamorro2, Jose Alejandro Vergel2, Ximena Espinosa1, Juan Carlos Vargas1, Carlos Angarita1, Jhon Edinson Parra1

1 El Tunal Hospital, Bogota, Cundinamarca, Colombia
2 Fundación Universitaria de Ciencias de la Salud, Bogota, Colombia

DOI: 10.2478/jccm-2025-0026

Introduction: Hyperglycemia and diabetes have been identified as risk factors for severe COVID-19 and death, with a high rate of reported de novo diabetes. We evaluated their incidence and relationship with adverse outcomes in critically ill COVID-19 patients.
Methods: Prospective single-center longitudinal cohort study in adults hospitalized in intensive care units for confirmed COVID-19. ROC curves for serum glucose and glycated hemoglobin were plotted in relation to 60-day mortality. A Cox proportional hazards model was used to assess the association of diabetes and de novo diabetes with 60-day mortality.
Results: 547 patients were included, with a mean age of 59.8 years; 133 (24.3%) had a history of diabetes, and 67 (12.2%) had de novo diabetes. At 60 days, 317 (57.9%) had died. For mortality, the AUC for glucose at admission was 0.55 (95% CI: 0.48 – 0.62) and 0.51 (95% CI: 0.41 – 0.62) for glycated hemoglobin. In the Cox model, diabetes had an HR of 0.888 (95% CI: 0.695 – 1.135, p: 0.344), history of DM had an HR of 0.881 (95% CI: 0.668 – 1.163, p: 0.371), and de novo diabetes had an HR of 0.963 (95% CI: 0.672 – 1.378, p: 0.835).
Conclusion: There was a high incidence of de novo diabetes in patients hospitalized in intensive care for COVID-19. Neither hyperglycemia, history of diabetes, nor de novo diabetes were associated with the development of complications or 60-day mortality.

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Angioedema: Is ICU admission warranted? A single institution assessment

Madeleine Brill-Edwards1, W. Chase Hamilton2, Erika J. Yoo3, Jennifer Costello4, George J. Koenig Jr.4, Murray J. Cohen4, Joshua A. Marks4

1 Eastern Virginia Medical School, Norfolk, VA, USA
2 Department of Anesthesia, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA USA; Bethlehem Campus, St. Luke’s University Health Network, Fountain Hill, PA, USA
3 Division of Pulmonary, Allergy and Critical Care Medicine, Jefferson-National Jewish Health Jane and Leonard Korman Respiratory Institute, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
4 Division of Acute Care Surgery, Department of Surgery, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA USA

DOI: 10.2478/jccm-2025-0023

Introduction: Angioedema has potential for rapid airway decompensation requiring intervention. Patients are often admitted to an ICU for “airway watch.” There is a lack of evidence to support which patients require this.
Aim: We aimed to characterize admission patterns and outcomes of angioedema patients at our institution to assess resource utilization and necessity of ICU use. We hypothesized that patients not requiring intubation upon presentation are safe to manage outside the ICU.
Materials and Methods: Retrospective chart review of patients admitted to our urban academic quaternary referral institution with angioedema ICD-10 codes between 2017 and 2020. Charts reviewed for demographics, etiology, admission location, level of care, length of stay (LOS), intubation information, discharge destination, and specific treatment administered. Statistical analysis included a t-test for continuous variables (LOS).
Results: Of 135 encounters for angioedema, 117 patients were admitted. 50 were admitted to an ICU. Patients were evenly split based on sex, majority black, and the most common etiology was ACE-inhibitor use. 20 required airway intervention with intubations primarily outside the ICU setting and only 2 in the ICU. 1 surgical airway performed in the ED. The mean time from presentation to intubation was 2.7 hours (Min 0h; Max 7.5h). The average ICU LOS for non-intubated patients was 1.1 days, with hospital LOS 1.5 days compared to 0.25 days for those not admitted to an ICU (p<0.001). For intubated patients, average ICU LOS was 4.3 days, with hospital LOS 6.2 days. All intubated patients were successfully liberated from the ventilator. No deaths occurred.
Conclusion: Most angioedema encounters did not require airway intervention within the first hours of presentation. Airway decompensation and intervention mostly occurred prior to the ICU setting. ICU resources should be carefully allocated and may be unnecessary for patients presenting with angioedema who are not intubated on initial evaluation.

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Non-invasive SpO2/FiO2 ratio (SFR) as surrogate for PaO2/FiO2 ratio (PFR): A scoping review

Madhura Reddy1, Malavika Kulkarni2, Sushma Thimmaiah Kanakalakshmi2, Laxmi Shenoy2, Rama Rani KrishnaBhat2

1 Department of Respiratory Therapy, Manipal College of Health Professions, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
2 Department of Anesthesiology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India

DOI: 10.2478/jccm-2025-0024

Patient oxygenation significantly impacts clinical outcomes, and continuous monitoring is essential, especially in critical care settings where hypoxia is the leading cause of mortality. PFR (PaO2/FiO2 ratio or P/F ratio) is an invasive method for measuring oxygenation requiring arterial blood gas (ABG) sampling, however it carries complications making non-invasive methods more desirable. SFR (SpO2/FiO2 ratio or S/F ratio), a non-invasive tool based on pulse oximetry, provides a cost-effective and rapid way to monitor oxygenation status, especially in settings where advanced methods are unavailable. A total of 575 articles were screened from databases including Web of Science, Scopus, PubMed, and CINAHL, with 32 articles meeting the inclusion criteria for this scoping review wherein SFR was used as a surrogate for PFR and a diagnostic tool for acute lung injury and ARDS. A total of 81,637 patient records were analyzed, including ABG values, pulse oximetry readings, mechanical ventilator settings, and patient diagnoses. The study population included adults, pediatric patients, and neonates admitted to critical care units, with common diagnoses including acute hypoxemic respiratory failure, ARDS, and COVID-19. In the context of COVID-19, SFR was used to predict the need for mechanical ventilation, with a cut-off of 300 indicating a threshold for imminent ventilation requirement. The studies demonstrated statistically significant sensitivity and specificity for SFR, highlighting its utility as a non-invasive tool for assessing oxygenation status. SFR has shown potential as a reliable non-invasive surrogate for determining oxygenation status across all populations.

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Transient systolic anterior motion in a patient with junctional rhythm in the intensive care unit

Alfred Ibrahimi1, Saimir Kuci1, Ormir Shurdha2, Romina Teliti3

1 Division of Intensive Care, Mother Teresa Hospital, Tirana, Albania
2 Division of Cardiology, Mother Teresa Hospital, Tirana, Albania
3 Division of Cardiology, German Hospital International, Tirana, Albania

DOI: 10.2478/jccm-2025-0021

Systolic anterior motion (SAM) of the mitral valve refers to the unusual movement of the anterior and sometimes the posterior mitral valve leaflets toward the left ventricular outflow tract (LVOT) during systole. This phenomenon is most frequently associated with the asymmetric septal variant of hypertrophic cardiomyopathy (HCM), but it can also occur in conditions like acute myocardial infarction, diabetes mellitus, hypertensive heart disease, after mitral valve repair, and even in asymptomatic individuals during dobutamine stress tests. We present a case of transient SAM induced by a junctional rhythm along with high doses of dobutamine and nitroglycerin in an intensive care unit (ICU) setting. Transesophageal echocardiography (TEE) played a crucial role in detecting SAM and showed that transitioning from a junctional rhythm to a ventricular paced rhythm led to an improvement in the SAM condition.

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Comparative assessment of hemodynamic changes and outcomes in ventilator weaning

Dina Zeid Roushdy, Hossam Ahmed Saad, Randa Aly Soliman, Mohammed Aly Shehata, Mohammed Amin Fakhir

Cairo University Kasr Alainy Faculty of Medicine, Cairo, Egipt

DOI: 10.2478/jccm-2025-0022

Introduction: Mechanical ventilation is fundamental for the management of critically ill patients. The mode of mechanical ventilation may impact the patient in different ways. This study aimed to assess the hemodynamic changes occurring when transitioning between Volume-Controlled Ventilation (VCV) to Variable Pressure Support (VPS) and VCV to Pressure Support (PS) by echocardiography. Also, a comparison between the spontaneous breathing modes in terms of outcomes, specifically, weaning of mechanical ventilation, days on a ventilator, hospital days, and survival, was conducted.
Methods: This prospective observational study was conducted on 40 mechanically ventilated patients who showed readiness for weaning from Mechanical ventilation. When transitioning between VCV and VPS in arm A and from VCV to PS in arm B, an echocardiographic assessment (transesophageal echocardiography and transthoracic echocardiography) was performed. Both modes were further compared in terms of weaning and the success of liberation from mechanical ventilation.
Results: By comparing both arms, there was a significant difference in velocity time integral (VTI) and stroke volume (SV) for TEE and TTE with p-values of 0.044, 0.022, and 0.05, 0.059, respectively. Also, the cardiac output (CO) showed a statistically significant difference between both arms with a p-value of 0.04. On the other side, there was no statistically significant difference between both arms in terms of ventilator days (p-value of 0.88), length of stay (p-value of 0.651), weaning trial success (p-value of 0.525), and survival rate (p-value of 0.525).
Conclusion: The study showed that VPS is a promising modality that can be used in place of PS as a weaning mode. It provides better patient comfort and a more physiological way of breath delivery. The study also concluded that TTE and TEE will show similar results in most patients and that both can be used interchangeably.

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The challenge of antimicrobial resistance in intensive care setting

Prisco Piscitelli1,2, Vincenzo Costigliola1, Leonard Azamfirei3

1 European Medical Association (EMA), Bruxelles, Belgium
2 Department of Psychology and Health Sciences, Pegaso Telematic University, Naples, Italy
3 Department of Anesthesiology and Intensive Care, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, Romania

DOI: 10.2478/jccm-2025-0020

Antimicrobial resistance (AMR) is a growing global health crisis, also in the frame of One Health perspective (1). This problem represents a dramatic emergency in critical care settings like intensive care units (ICUs), where patients are most vulnerable, also because of persistent lack in the pharmaceutical pipeline for the development of new antibiotics (2-4). ICUs are the front line in managing patients with life-threatening conditions, such as severe infections, trauma, and organ failure. Therefore, ICUs present unique conditions – as patients are critically ill, immunocompromised, and often subjected to invasive procedures and extended hospital stays — provide an ideal environment for the emergence and spread of resistant pathogens. AMR poses significant challenges for healthcare providers in ICUs, where timely and effective antibiotic treatment is crucial, directly impacting on clinical outcomes, mortality rates and increased healthcare costs (5). [More]

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