Category Archives: Volume 11

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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Characteristics and temporality of the ventilatory techniques in the management of acute respiratory distress syndrome: A scoping review

Théo Battalian1, Raúl Escudero Romero1, Arianne Barzaga Molina2

1 Department of Physiotherapy, School of Medicine, Universidad San Pablo-CEU, CEU Universities, Boadilla del Monte, Spain
2 Department of Kinesiology, Faculty of Medicine, Clínica Alemana Universidad del Desarrollo, Santiago, Chile

DOI: 10.2478/jccm-2025-0019

Introduction: Acute Respiratory Distress Syndrome (ARDS) is a critical condition characterised by acute respiratory failure due to increased alveolar-capillary membrane permeability. This leads to non-cardiogenic pulmonary oedema, hypoxemia, and impaired respiratory compliance, significantly impacting patients’ survival and quality of life. The management of ARDS involves various ventilatory and non-ventilatory therapies. Understanding the optimal timing and application of these therapies is crucial for improving patient outcomes.
Aim of the study: This scoping review aims to identify and synthesise the ventilatory techniques used in managing ARDS, focusing on their temporality and the interplay between different therapies. The study seeks to synthesize the available evidence and summarize current management strategies, highlighting areas for further research and improvement in ARDS care.
Material and Methods: A systematic search of PubMed, EBSCO, and ScienceDirect databases was conducted, following the Joanna Briggs Institute guidelines (2015), for articles published between 2013 and 2023. Studies involving adult patients (18 years or older) diagnosed with ARDS and receiving ventilatory support in the ICU were included. Exclusion criteria included other acute respiratory pathologies, clinically extreme obese patients, and patients with tracheostomy.
Results: 437 articles were identified through the database search, of which 23 met the inclusion criteria and were included in the final review. Most articles were published between 2015-2019 (43.5%), originated from the USA (34.78%), and employed observational study designs (73.91%). The included studies reported on patients aged between 23 and 79 years, with intrapulmonary causes being the most common aetiology for ARDS. Various ventilatory strategies were identified, including conventional oxygen therapy, high-flow nasal cannula (HFNC), non-invasive ventilation (NIV), invasive ventilation (IMV), and combined approaches. Temporality was reported in 35% of the articles, but none of them as their primary focus.
Conclusions: The review highlights the diversity of ventilatory techniques employed in ARDS management and the importance of individualizing treatment strategies based on patient response and disease severity. The temporality of these interventions remains a crucial aspect, requiring further investigation to establish clearer guidelines for optimizing the timing and sequence of ventilatory support in ARDS. The findings underscore the need for future research to focus on patient-centred outcomes and the long-term implications of ARDS management, including quality of life and functional status.

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A brief report on the association of preoperative hematological indices and acute deep vein thrombosis following total hip arthroplasty for osteoarthritis

Razvan Marian Melinte1, Matei Florin Negrut2, Daniel Oltean-Dan3, Adrian Dumitru Ivanescu4, Tudor-Mihai Magdas5, Oana Antal6, Adela Hilda Onutu7, Marian Andrei Melinte8, Robert Bolcas6

1 1st Department of Orthopedics and Traumatology, “Iuliu Hațieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania; Department of Orthopedics, Regina Maria Health Network, Targu Mures, Romania
2 “Iuliu Hațieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
3 Department of Orthopedics and Traumatology, County Emergency Hospital, Cluj-Napoca, Romania; MedLife Humanitas Hospital, Cluj-Napoca, Romania
4 Department of Anatomy, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Targu Mures, Romania
5 Department of Anatomy, “Iuliu Hațieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
6 2nd Department of Anesthesia and Intensive Care, “Iuliu Hațieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
7 Department of Anesthesia and Intensive Care, Orthopaedics and Traumatology Clinic, County Emergency Hospital, Cluj-Napoca, Romania
8 George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania

DOI: 10.2478/jccm-2025-0018

Introduction: Total hip arthroplasty (THA) is a standard orthopedic procedure. Deep vein thrombosis (DVT) and pulmonary embolism are potential life-threatening postoperative complications.
Aim of the study: This study aimed to assess the prognostic value of systemic inflammatory indices [monocyte-to-lymphocyte ratio (MLR), neutrophil-to-lymphocyte ratio (NLR), platelets-to-lymphocyte ratio (PLR), systemic inflammatory index (SII), systemic inflammation response index (SIRI), and aggregate index of systemic inflammation (AISI)] and their potential association with acute postoperative DVT.
Materials and methods: We designed a multicentric, retrospective, observational cohort study, including adult patients undergoing elective HTA. Patients were divided into two groups, the DVT and non-DVT groups. We investigated the development of acute DVT early, and at 4 weeks after surgery and also registered length of hospital stay and mortality. All demographic data and laboratory data, hematological indices were extracted from patients files.
Results: 199 patients were included. Of those, 12 (6.03%) developed DVT and 187 (93.97%) did not. There was no statistically significant difference between patient age, gender, BMI, smoking status or comorbidities. No difference was founds between the two groups regarding median values of MLR (0.31 vs 0.27, p=0.12), NLR (3.16 vs 2.42, p=0.27), PLR (163.39 vs 123.01, p=0.27), SII (660.26 vs 568.52, p=0.33), SIRI (67.5 vs 65.26, p=0.89) and AISI (302.35 vs 290.48, p=0.85). Length of hospital stay was not significantly different (median 9 days in the DVT group vs 7 days in the non-DVT group, p=0.38), but mortality was significantly higher in the DVT group (3 deaths vs none in the non-DVT group, p<0.001).
Conclusion: MLR, NLR, PRL, SII, SIRI and AISI were not associated with the development of acute DVT following HTA in our study population.

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Ability to identify patient-ventilator asynchronies in intensive care unit professionals: A multicenter cross-sectional analytical study

Andrés Mauricio Enríquez Popayán1, Iván Ignacio Ramírez2, Juan Felipe Zúñiga3, Ruvistay Gutierrez-Arias4, Mayda Alejandra Jiménez Pérez5, Henry Mauricio Parada-Gereda6, Luis Fernando Pardo Cocuy7, Ana Lucia Rangel Colmenares8, Nubia Castro Chaparro9, Ana Pinza Ortega10, Jorge Martínez Díaz11, Johanna Hurtado Laverde12, Joismer Alejandro Henao Cruz13

1 Departamento de Fisioterapia en Cuidado Intensivo, GyO Medical, Yopal, Colombia; Departamento de Fisioterapia en Cuidado Intensivo, Clínica SIMALINK, Yopal, Colombia
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, Facultad de Ciencias de la Salud, Universidad Diego Portales, Santiago, Chile
3 Departamento de Fisioterapia en Cuidado Intensivo, Clínica de Occidente, Cali, Colombia
4 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, Faculty of Rehabilitation Sciences, Universidad Andres Bello, Santiago, Chile
5 Departamento de Fisioterapia en Cuidado Intensivo, Fundación Hospital San Pedro, Pasto, Colombia
6 Unidad de Cuidado Intensivo, Clínica Reina Sofia, Bogotá, Colombia; Clínica Colsanitas, Grupo de Investigación en Nutrición Clínica y Rehabilitación-Keralty, Bogotá, Colombia. ???Especialización de Fisioterapia en Paciente Adulto Critico, Universidad del Rosario, Bogotá, Colombia
7 Departamento de Fisioterapia en Cuidado Intensivo, Hospital Universitario Mayor Méderi, Bogotá, Colombia; Especialización de Fisioterapia en Paciente Adulto Critico, Universidad del Rosario, Bogotá, Colombia
8 Departamento de Fisioterapia en Cuidado Intensivo, Clínica Norte, Cúcuta, Colombia; Departamento de Fisioterapia en Cuidado Intensivo, Clínica San José, Cúcuta, Colombia
9 Departamento de Cuidado Intensivo, Lumira SAS, Cali, Colombia
10 Departamento de Fisioterapia en Cuidado Intensivo, Fundación Hospital San Pedro, Pasto, Colombia; Programa de Fisioterapia, Universidad Mariana, Pasto, Colombia; Grupo de Investigación en Medicina Critica GMC, Fundación Hospital San Pedro, Pasto, Colombia
11 Departamento de Cuidado Intensivo, Fundación Hospital San Pedro, Pasto, Colombia; Programa de Medicina, Fundación Universidad San Martin, Pasto, Colombia; Grupo de Investigación en Medicina Critica GMC, Fundación Hospital San Pedro, Pasto, Colombia
12 Programa de Terapia Respiratoria, Universidad Manuela Beltrán, Bogotá, Colombia
13 Departamento de Fisioterapia en Cuidado Intensivo, Hospital Universitario de Caldas, Manizales, Colombia

DOI: 10.2478/jccm-2025-0017

Introduction: Patient-ventilator asynchrony (PVA) is frequent in intensive care. Its presence is associated with prolonged days of mechanical ventilation and may lead to increased mortality in the intensive care unit (ICU) and hospital. Little is known about the ability of Colombian intensive care professionals to identify asynchronies, and the factors associated with their correct identification are not apparent.
Aim of the study: To describe the ability of Colombian intensive care professionals to identify patient-ventilator asynchronies (PVA) using waveform analysis. In addition, to define the characteristics associated with correctly detecting PVA.
Material and methods: We conducted a multicenter, cross-sectional, national survey-based study between January and August 2024. Colombian physiotherapists, respiratory therapists, nurses and intensive care physicians from 24 departments participated in the study. An online survey was used. They were asked to identify six different PVAs presented as videos. The videos were displayed using pressure/time and flow/time waveform of a Puritan Bennett 840 ventilator.
Results: We recruited 900 participants, 60% female, most of whom were physiotherapists (53%). Most professionals had specialty training in critical care (42%), and 32% reported having specific PVA training. Double triggering was the most frequently identified PVA (75%). However, only 3.67% of participants recognized all six PVAs. According to multiple logistic regression analysis, working in a mixed unit (OR 2.59; 95% CI 1.19 – 5.54), caring for neonates (OR 5.19; 95% CI 1.77 – 15.20), and having specific training (OR 2.38; 95% CI 1.16 – 4.76) increases the chance of correctly recognizing all PVAs.
Conclusion: In Colombia, a low percentage of professionals recognize all PVAs. Having specific training in this topic, working in mixed ICUs and neonatal intensive care was significantly associated with identifying all PVAs.

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Latent class analysis for identification of sub-phenotypes predicting prognosis in hospitalized out-of-hospital cardiac arrest

Yuki Kishihara1, Hideto Yasuda1–4, Masahiro Kashiura1, Shunsuke Amagasa5, Hiroyuki Tamura1, Yutaro Shinzato1, Takashi Moriya1

1 Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
2 Department of Clinical Research Education and Training Unit, Keio University Hospital Clinical and Translational Research Center, Tokyo, Japan
3 School of Nursing, Midwifery and Social Work, UQ Centre for Clinical Research, The University of Queensland, Australia
4 School of Nursing and Midwifery; Alliance for Vascular Access Teaching and Research, Griffith University, Australia
5 Department of Emergency and Transport Medicine, National Center for Child Health and Development, Tokyo, Japan

DOI: 10.2478/jccm-2025-0016

Aim of the study: To determine which out-of-hospital cardiac arrest (OHCA) patients should receive advanced treatment is extremely challenging. The objective was to identify sub-phenotypes predicting the prognoses of adult OHCA patients by latent class analysis (LCA) using data up to just after admission.
Material and Methods: We conducted a retrospective observational study using multicentre OHCA registry from 95 Japanese hospitals including adult non-traumatic hospitalized OHCA. The primary outcome was 30-day favourable neurological outcome. Our LCA used clinically relevant variables up to just after admission and the optimal class number was determined from clinical importance and Bayesian information criterion. The associations between sub-phenotypes and outcomes were analysed using univariate logistic regression analysis with odds ratios (ORs) and 95% confidence intervals (CIs).
Results: Our LCA included 2,162 patients and identified four sub-phenotypes. The base excess on hospital arrival had the highest discriminative power. Thirty-day favourable neurological outcomes were observed in 526 patients (24.3%), including 284 (53.8%) in Group 1, 179 (21.2%) in Group 2, 26 (11.4%) in Group 3, and 37 (6.6%) in Group 4. Prehospital return of spontaneous circulation (ROSC) was achieved in 1,009 patients (46.7%), including 379 (81.8%) in Group 1, 340 (40.3%) in Group 2, 115 (50.4%) in Group 3, and 175 (31.1%) in Group 4. Univariate logistic regression analysis for primary outcome using Group 4 as reference revealed ORs (95% CI) of 16.5 (11.4–24.1) in Group 1, 3.83 (2.64–5.56) in Group 2, and 1.83 (1.08–3.10) in Group 3.
Conclusions: Our LCA classified OHCA into four sub-phenotypes showing significant differences for prognosis. In cases who achieved prehospital ROSC, it might be meaningful to continue advanced therapeutic interventions.

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