Category Archives: JCCM 2025, Vol. 11, Issue 1

The implementation gap in critical care: From nutrition to ventilation

Razvan Azamfirei

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

DOI: 10.2478/jccm-2025-0011

Critical care medicine pushes boundaries. We talk about personalized medicine and wax poetic on sophisticated trial design, all while debating using diaphragmatic ultrasound for ventilator weaning. Our excitement about the latest mechanical circulatory support device or novel vasopressor is matched only by the rush to share the latest “groundbreaking” meta-analysis – inevitably analyzing the same five trials as the last one, just with a different statistical twist. None of this is to say that such discussions do not have merit. But our fascination with tomorrow’s breakthroughs disguises a more fundamental challenge: we consistently fail to deliver basic, routine care at the bedside.[More]

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Machine learning to predict extubation success using the spontaneous breathing trial, objective cough measurement, and diaphragmatic contraction velocity: Secondary analysis of the COBRE-US trial

Fabio Varón-Vega1,2, Eduardo Tuta-Quintero1,2,3, Adriana Maldonado-Franco3, Henry Robayo-Amórtegui3, Luis F Giraldo-Cadavid1,3, Daniel Botero-Rosas3

1 Fundación Neumológica Colombiana, Bogotá, Colombia
2 Fundación Cardioinfantil Instituto de Cardiología, Bogotá, Colombia
3 Universidad de La Sabana, Chía, Colombia
4 Fundación Clínica Shaio, Bogotá, Colombia

DOI: 10.2478/jccm-2025-0009

Introduction: Determining the optimal timing for extubation in critically ill patients is essential to prevent complications. Predictive models based on Machine Learning (ML) have proven effective in anticipating weaning success, thereby improving clinical outcomes.
Aim of the study: The study aimed to evaluate the predictive capacity of five ML techniques, both supervised and unsupervised, applied to the spontaneous breathing trial (SBT), objective cough measurement (OCM), and diaphragmatic contraction velocity (DCV) to estimate a favorable outcome of SBT and extubation in critically ill patients.
Material and Methods: A post hoc analysis conducted on the COBRE-US study. The study included ICU patients who underwent evaluation of SBT, OCM, and DCV. Five ML techniques were applied: unsupervised and supervised to the data in both a training group and a test group. The diagnostic performance of each method was determined using accuracy.
Results: In predicting SBT success, all supervised methods displayed the same accuracy in the training group (77.3%) and in the test group (69.6%). In predicting extubation success, decision trees demonstrated the highest diagnostic accuracy, 89.8% for the training group and 95.7% for the test group. The other supervised methods also showed a good diagnostic accuracy: 85.9% for the training group and 93.5% for the test group.
Conclusions: In predictive models using OCM, DCV, and SBT as input variables through five ML techniques, decision trees and artificial neural networks demonstrated the best diagnostic performance. This suggests that these models can effectively classify patients who are likely to succeed in SBT and extubation during the weaning process from mechanical ventilation.

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Choking and laryngospasm: Exploring commonalities and treatment strategies

Gad Estis1, Asia Estis-Deaton2, Tiberiu Ezri3

1 Herzliya Medical Center, Herzliya, Israel
2 Assuta Ashdod Hospital, Ashdod, Israel
3 Kaplan Medical Center, Rehovot, Israel

DOI: 10.2478/jccm-2025-0010

Choking is a significant health concern associated with substantial morbidity and mortality. Despite ongoing efforts, an optimal solution remains elusive. We propose that this may stem from an overemphasis on mechanical obstruction as the primary cause. Notably, a foreign body does not always completely occlude the airway. For instance, Saccomanno et al. reported that fish bones were implicated in 67% of choking incidents [1], suggesting that defensive airway reflexes may play a critical role beyond mere mechanical obstruction. [More]

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Risk factors and outcomes of critically ill pregnant COVID-19 patients: Experience from the first and second waves of the pandemic

Dita Aditianingsih1,2, Noor Hafidz1,2, Aino Nindya Auerkari1,2, Zarah Tin Cahyaningrum1,
El Nissi Leonard1, Chrisella Annabelle1

1 Department of Anesthesiology and Intensive Care, Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas Indonesia, Indonesia
2 Department of Anesthesiology and Intensive Care, Universitas Indonesia Hospital, Indonesia

DOI: 10.2478/jccm-2025-0008

Introduction: Understanding the association between risk factors and clinical outcomes of COVID-19 can lead to identifying suitable management strategies for reducing the mortality rate among maternal COVID-19 patients in the ICU.
Aim of the Study: This study aims to investigate the clinical outcomes and risk factors associated with pregnant and postpartum women diagnosed with COVID-19 and admitted to the intensive care unit (ICU) between May 2020 and September 2021.
Materials and Methods: This retrospective cohort study was conducted at the Universitas Indonesia Hospital. Secondary data was collected from the medical records to include all pregnant and postpartum women diagnosed with confirmed COVID-19 admitted to the hospital during the research period.
Results: The study included 113 patients and found that admission to the ICU, age, and gestational age significantly influenced clinical outcomes, with a mortality rate of 42.11% among ICU-admitted patients. Pre-existing comorbidities such as type-2 diabetes mellitus, congestive heart failure, and coronary artery disease were associated with ICU admission. Having at least one comorbidity was found to increase the mortality rate by six-fold.
Conclusions: The study emphasizes the importance of monitoring and evaluating maternal and fetal complications during COVID-19 infection, highlighting the need for multidisciplinary management involving intensivists, obstetricians, anesthesiologists, and infectious disease specialists. The findings underscore the significance of baseline health status in treatment planning and the potential for evidence-based interventions to improve maternal outcomes and pregnancy preservation. Further research is warranted to validate these results and enhance understanding of the underlying pathophysiology.

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Midodrine initiation criteria, dose titration, and adverse effects when administered to treat shock: A systematic review and semi-quantitative analysis

Madeleine M. Puissant, Kaitlin J Armstrong, Richard R Riker, Samir Haydar, Tania D Strout, Kathryn E Smith, David B Seder, David J Gagnon

Maine Medical Center, Portland, USA

DOI: 10.2478/jccm-2025-0007

Objective: Systematically examine the literature describing midodrine to treat shock and to summarize current administration and dosing strategies.
Data sources: Structured literature search conducted in MEDLINE (PubMed) from inception through May 10, 2023.
Study Selection and Data Extraction: Abstracts and full texts were assessed for inclusion by two blinded, independent reviewers. English-language publications describing use of midodrine in adult patients with shock were included. Data were extracted by two blinded, independent abstractors using a standardized extraction tool. Quality assessments were completed by paired reviewers using JBI methodology.
Data Synthesis: Fifteen of 698 (2%) screened manuscripts were included with 1,714 patients with a variety of shock types. Seven studies (47%) were retrospective, two (13%) prospective observational, and six (40%) randomized controlled studies. Midodrine was initiated to facilitate intravenous vasopressor (IVP) weaning in most (11, 73%) studies; only two (13%) reported IVP weaning protocol use. Starting doses were 10 mg every 8 hours (4, 27%) or three times a day (3, 20%), 20 mg every 8 hours (2, 13%); six studies (40%) did not report initial midodrine dosing. A midodrine titration protocol was reported in 6 (40%) studies. Thirteen (87%) studies evaluated for bradycardia, identified in 6 (46%) studies among 204 patients; only one (0.5%) patient required midodrine discontinuation. Three (20%) studies reported on hypertension with an incidence of 7-11%. Four (27%) studies assessed for ischemia; 5/1128 (0.4%) patients experienced mesenteric ischemia requiring midodrine discontinuation.
Relevance to Patient care and Clinical Practice: This review explores the pragmatic details involved in initiating, titrating, and weaning midodrine for the bedside clinician and identifies rates of adverse events and complications.
Conclusions: Published literature describing midodrine use for shock is heterogeneous and comprised primarily of low or very low quality data. Future controlled trials addressing the shortcomings identified in this systematic review are warranted.

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Association between hospital case volume and mortality in pediatric sepsis: A retrospective observational study using a Japanese nationwide inpatient database

Shingo Ohki1,2, Makoto Otani3, Shinichi Tomioka1,4, Kosaku Komiya5, Hideki Kawamura6, Taka-aki Nakada7, Satoshi Nakagawa8, Shinya Matsuda3, Nobuaki Shime1

1 Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
2 Shonan Kamakura General Hospital, Kamakura, Japan
3 University of Occupational and Environmental Health, Kitakyushu, Japan
4 Kotonoha Collaboration Clinic, Kitakyushu, Japan
5 Faculty of Medicine, Oita University, Oita, Japan
6 Kagoshima University Hospital, Kagoshima, Japan
7 Graduate School of Medicine, Chiba University, Chiba, Japan
8 National Center for Child Health and Development, Tokyo, Japan

DOI: 10.2478/jccm-2025-0006

Introduction: The survival benefits of treatment at high-volume hospitals (HVHs) are well-documented for several critical pediatric conditions. However, their impact on pediatric sepsis, a leading cause of mortality among children, remains understudied.
Aim of the study: To investigate the association between hospital case volume and mortality rates in pediatric sepsis.
Material and Methods: We conducted a retrospective cohort study using data from the Diagnosis Procedure Combination database. The study included patients who met the following criteria: 1) aged 28 days to 17 years; 2) discharged from the hospital between April 2014 and March 2018; 3) had a sepsis diagnosis coded under the International Classification of Diseases, 10th revision; 4) underwent blood cultures on hospital admission day (day 0) or day 1; 5) received antimicrobial agents on day 0 or 1; and 6) required at least one organ support measure (e.g., mechanical ventilation or vasopressors) on day 0 or 1. Hospitals were categorized by case volume during the study period, with HVHs defined as those in the highest quartile and low-volume hospitals (LVHs) as those in the remaining quartiles. In-hospital mortality rates between HVH and LVH groups were compared using mixed-effects logistic regression analysis with propensity score (PS) matching.
Results: A total of 934 pediatric patients were included in the study, with an overall in-hospital mortality rate of 16.1%. Of them, 234 were treated at 5 HVHs (≥26 patients in 4 years), and 700 at 234 LVHs (<26 patients in 4 years). Upon PS matching, patients treated at HVHs demonstrated significantly lower odds of in-hospital mortality compared with those treated at LVHs (odds ratio, 0.42; 95% confidence interval, 0.22–0.80; P = 0.008).
Conclusions: In pediatric patients with sepsis, treatment at HVHs was associated with lower odds of in-hospital mortality.

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What proteins and albumins in bronchoalveolar lavage fluid and serum could tell us in COVID-19 and influenza acute respiratory distress syndrome on mechanical ventilation patient – A prospective double center study

Anita Djurdjevic Svraka1, Dragan Svraka1,2, Bosa Mrjanic Azaric1, Jovana Malic1,2, Goran Baric1,2, Pedja Kovacevic1,2

1 Faculty of Medicine, University of Banja Luka, Banjaluka, Bosnia and Herzegovina
2 University Clinical Centre of the Republic of Srpska

DOI: 10.2478/jccm-2025-0005

Introduction: The extent of in vivo damage to the alveolar-capillary membrane in patients with primary lung injury remains unclear. In cases of ARDS related to COVID-19 and Influenza type A, the complexity of the damage increases further, as viral pneumonia cannot currently be treated with a causal approach.
Aims of the study: Our primary goal is to enhance the understanding of Acute Respiratory Distress Syndrome (ARDS) by demonstrating damage to the alveocapillary membrane in critically ill patients with COVID-19 and influenza type A. We will achieve this by measuring the levels of proteins and albumin in bronchoalveolar fluid (BAL) and serum. Our secondary objective is to assess patient outcomes related to elevated protein and albumin levels in both BAL and blood serum, which will deepen our understanding of this complex condition.
Materials and methods: Bronchoalveolar lavage (BAL) fluid and serum samples were meticulously collected from a total of 64 patients, categorized into three distinct groups: 30 patients diagnosed with COVID-19-related acute respiratory distress syndrome (ARDS), 14 patients with influenza type A (H1N1 strain), also experiencing ARDS, and a control group consisting of 20 patients who were preoperatively prepared for elective surgical procedures without any diagnosed lung disease. The careful selection and categorization of patients ensure the robustness of our study. BAL samples were taken within the first 24 hours following the commencement of invasive mechanical ventilation in the intensive care unit, alongside measurements of serum albumin levels. In the control group, BAL and serum samples were collected after the induction of general endotracheal anaesthesia.
Results: Patients in the COVID-19 group are significantly older than those in the Influenza type A (H1N1) group, with median ages of 72.5 years and 62 years, respectively (p < 0.01, Mann-Whitney U test). Furthermore, serum albumin levels (measured in g/L) revealed significant differences across all three groups in the overall sample, yielding a p-value of less than 0.01 according to ANOVA. In terms of treatment outcomes, serum albumin levels also exhibited a significant correlation, with a p-value of 0.03 (Mann-Whitney U test). A reduction in serum albumin levels (below 35 g/L), combined with elevated protein levels in bronchoalveolar lavage (BAL), serves as a predictor of poor outcomes in patients with acute respiratory distress syndrome (ARDS), as indicated by a p-value of less than 0.01 (ANOVA).
Conclusions: Our findings indicate that protein and albumin levels in bronchoalveolar lavage (BAL) fluid are elevated in severe acute respiratory distress syndrome (ARDS) cases. This suggests that BAL can effectively evaluate protein levels and fractions, which could significantly assist in assessing damage to the alveolocapillary membrane. Additionally, the increased albumin levels in BAL, often accompanied by a decrease in serum albumin levels, may serve as a valuable indicator of compromised integrity of the alveolar-capillary membrane in ARDS, with potential implications for patient care.

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Hypercapnia outcome in COVID-19 acute respiratory distress syndrome patients on mechanical ventilator: A retrospective observational cohort

Sarwat Rasheed1,2, Sidra Javed1,2, Thanyat Rasheed3, Shaiza Farman1,2, Elisha Shalim1,2

1 Sindh Infectious Disease Hospital and Research Centre, Karachi, Pakistan
2 Dow University of Health Sciences, Karachi, Pakistan
3 Patel Hospital, Karachi, Pakistan

DOI: 10.2478/jccm-2025-0004

Introduction: Acute respiratory distress syndrome (ARDS) is characterized by progressive lung inflammation which leads to increased dead space that can cause hypercapnia and can increase the risk of patient morbidity and mortality. In an attempt to improve ARDS patient outcomes provision of protective lung ventilation has been shown to improve patient mortality but increases the incidence of hypercapnia. Therefore, the role of carbon dioxide in ARDS remains contradicted by conflicted evidence. This study aims to examine this conflicting relationship between hypercapnia and mortality in mechanically ventilated COVID-19 ARDS patients.
Methods: We conducted a retrospective cohort study. The data was collected from the medical records of the patients admitted with COVID-19 ARDS in Sindh Infectious Disease Hospital &Research Centre (SIDH & RC) from August 2020 to August 2022 and who received mechanical ventilation for more than 48 hours. The patients were grouped into severe and no severe hypercapnia groups based on their arterial blood carbon dioxide levels (PaCO2). To understand the effect of hypercapnia on mortality we performed multivariable logistic regression, and inverse probability-weighted regression to adjust for time-varying confounders.
Results: We included 288 patients to detect at least 3% of the effect on mortality. Our analysis revealed an association of severe hypercapnia with severe lung injury, low PaO2/FiO2, high dead space, and poor compliance. In univariate analysis severe hypercapnia showed higher mortality: OR=3.50, 95% CI (1.46-8.43). However, after, adjusting for disease severity hypercapnia is not found to be associated with mortality: OR=1.08, 95% CI (0.32 -3.64). The sensitive analysis with weighted regression also shows no significant effect on mortality: OR=1.04, 95% CI (0.95-1.14).
Conclusion: This study showed that hypercapnia is not associated with mortality in COVID-19 ARDS patients.

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Intraabdominal hypertension is less common than it used to be: A pilot step wedge trial

Shane Smith¹,²,³, Fran Priestap³, Neil Parry¹,²,³, Robert Arntfield⁴, Patrick Murphy⁵, Kelly Vogt²,³, Ian Ball¹,³,⁴

1 Office of Academic Military Medicine, Western University, London, Ontario, Canada
2 Department of Surgery, Western University, London, Ontario, Canada
3 London Health Sciences Centre Trauma Program, London, Ontario, Canada
4 Department of Medicine, Western University, London, Ontario, Canada
5 Department of Surgery, Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, Milwaukee, WI, USA

DOI: 10.2478/jccm-2025-0002

Objective: This is a pilot study to determine the feasibility of a multicentre stepped wedge cluster randomized trial of implementing the 2013 World Society of the Intraabdominal Compartment Syndrome (WSACS) guidelines as an intervention to treat intraabdominal hypertension (IAH) and abdominal compartment syndrome (ACS) in critically ill patients.
Design: Single-centre before-and-after trial, with an observation / baseline period of 3 months followed by a 9-month intervention period.
Setting: A 35 bed medical-surgical-trauma intensive care unit in a tertiary level, Canadian hospital.
Patients: Recruitment from consecutively admitted adult intensive care unit patients.
Intervention: In the intervention period, treatment teams were prompted to implement WSACS interventions in all patients diagnosed with IAH.
Measurements and Main Results: 129 patients were recruited, 59 during the observation period and 70 during the intervention period. Only 17.0% and 12.9%, respectively, met diagnostic criteria for IAH. Many recruited patients did not have intraabdominal pressures measured regularly per study protocol. There was no difference in ICU mortality for patients in either cohort or between those with and without IAH.
Conclusions: The incidence of IAH in our patient population has decreased significantly since 2015. This is likely due to a significant change in routine care of critically ill patients, especially with respect to judicious goal-directed fluid resuscitation. Patient recruitment and protocol adherence in this study were low, exacerbated by other staffing and logistical pressures during the study period. We conclude that a larger multicentre trial is unlikely to yield evidence of a detectable treatment effect.

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