Journal of Intensive Care Medicine

Moh, Ashton; Edwards, Felicity; Marella, Prashanti; Lavana, Jayshree; Marshall, Andrea; Tabah, Alexis; White, Kyle; Blank, Sebastiaan; Whebell, Stephen; Luke, Stephen; Garrett, Peter; White, Hayden; Laupland, Kevin; Attokaran, Antony; Ramanan, Mahesh

doi: 10.1177/08850666251415168pmid: 41564271

BackgroundPulmonary embolism may cause hemodynamic instability requiring vasoactive support, but evidence on guiding agent selection is very limited.MethodsA retrospective cohort study of adult admissions to 12 Intensive Care Units in Queensland, Australia between 2015–2021. Clinical and outcome data was obtained through statewide hospital databases.ResultsOf 89,123 admissions, 460 (0.6%) patients had a primary diagnosis of pulmonary embolism. Vasoactive infusions were administered within the first 24 h of ICU admission to 182/460 patients (39.6%) and 209/460 (45.4%) patients at any time during ICU admission. Norepinephrine was the most common (175/209; 83.7%), followed by epinephrine (37/209; 17.7%). The cohort had a median ICU length of stay of 3 days (IQR; 2-5), and a 30-day mortality rate of 11.3% (52/460). Higher vasoactive requirement on day-1 was associated with significantly higher 30-day mortality (odds ratio per 1-unit increase in vasoactive-inotrope score of 3.72, 95% confidence interval 1.80-8.75, P < .001).ConclusionPrimary diagnosis of PE is uncommon among ICU presentations but 45% of patients require vasoactive support. Norepinephrine was the most used vasoactive agent. Higher vasoactive requirements reflected greater illness severity and were associated with higher 30-day mortality.

Anwar, Deshni; Naidoo, Vasanthrie

doi: 10.1177/08850666261426336pmid: 41744384

Medical device-related pressure injuries (MDRPIs) represent a growing and often overlooked complication in critical care environments. These injuries, result from prolonged contact with essential therapeutic equipment such as endotracheal tubes, catheters, and monitoring devices, posing a significant threat to patient safety and recovery.This systematic review synthesizes current research on the incidence and prevalence of MDRPIs in intensive care units, highlighting key risk factors including immobility, impaired perfusion, and the complexity of care in critically ill populations. Attention is drawn to the variability in reporting standards and methodological inconsistencies across studies, which obscure the true burden of MDRPIs globally. In examining evidence from diverse healthcare systems, this review emphasizes the urgent need for standardized protocols, early detection strategies, and multidisciplinary approaches to prevent device-related tissue damage. Addressing this silent threat is vital not only to improve patient outcomes but also to reduce healthcare-associated costs and strengthen the culture of safety in critical care settings.

Portaccio, Ivonne; Genovese, Orazio; De Leonardis, Federico; Vitali, Ilaria; Picconi, Enzo; Morena, Tony Christian; Tosi, Federica; Orr, Audrey Marie; Noto, Artiom; Spinazzola, Giorgia; Murri, Rita; Conti, Giorgio; Piastra, Marco

Li, Yunlong; Cui, Shanpeng; Wen, Lianghe; Cao, Yang; Chen, Yin; Zheng, Junbo; Wang, Hongliang

doi: 10.1177/08850666261446861pmid: 42231585

BackgroundThe maintenance of iron metabolism is pivotal in preventing sepsis-associated acute kidney injury (SA-AKI). However, the optimal iron metabolism has been controversial in maintaining renal perfusion. This study aims to explore the iron metabolism markers in severe SA-AKI.MethodsPatients from MIMIC IV database retrieval, included in all sepsis correlation of acute kidney injury (aged > 18 years of age). Logistic regression and restricted cubic spline (RCS) regression were performed to explore the relationship between iron metabolism markers and severe SA-AKI.ResultsIn total 3204 patients with sepsis were included in this study. There were 1452 (45.32%) patients in the severe SA-AKI group. According to the RCS analysis, a significant (P overall < .001, P nonlinearity < .001) non-linear U-shaped correlation was observed between all iron metabolism markers and severe SA-AKI. After adjustment for all potential covariates, multivariate logistic regression showed that low SI group (OR:1.238, 95% CI: 1.028-1.491), high SI group (OR:1.323, 95% CI: 1.088-1.609), low TRF group (OR: 1.331, 95% CI: 1.101-1.610), heigh TRF group (OR: 1.239, 95% CI: 1.024-1.499), low TIBC group (OR: 1.331, 95% CI: 1.101-1.610), heigh TIBC group (OR: 1.239, 95% CI: 1.024-1.499), and heigh SF group (OR: 1.219, 95% CI: 1.004-1.479) were independent risk factors for severe SA-AKI.ConclusionsIron metabolism markers have a non-linear U-shaped relationship with severe SA-AKI. Therefore, monitoring Iron Metabolism levels helps to dynamically identify patients with a higher risk of developing severe SA-AKI.

Moreira Ferreira, Vanessa F.; Cervantes-Arslanian, Anna M.

doi: 10.1177/08850666251414094pmid: 42159362

Purpose of the research:Neurologic complications are common in patients with sepsis and are associated with worse outcomes, increased length of stay, and long-term disability. This review outlines the major neurologic syndromes encountered in the context of sepsis, including sepsis-associated encephalopathy (SAE), seizures, cerebrovascular events, and ICU-acquired weakness due to critical illness polyneuropathy and critical illness myopathy.Major findings:We take a pragmatic, bedside-oriented approach to guide clinicians in evaluating septic patients with neurologic symptoms, most commonly presenting with altered mental status. We highlight diagnostic challenges when sedation, metabolic abnormalities, or medications confound the neurologic examination. Beginning with the clinical presentation and neurological examination, we review diagnostic pathways involving neuroimaging, continuous electroencephalogram (EEG), and laboratory studies to differentiate SAE from other neurologic conditions that may require specific treatment. Each neurologic complication is explored in detail, with emphasis on key exam findings, diagnostic strategies, and management principles. We also discuss the evolving understanding of central nervous system involvement in sepsis, including blood-brain barrier disruption, neuroinflammation, and microvascular injury as well as the long-term neurologic consequences of sepsis, including post-sepsis syndrome, cognitive impairment, increased risk of epilepsy, and increased stroke risk.Conclusions:Neurological complications are frequent, clinically important, and often underrecognized in sepsis. By providing a structured, practical framework, this review supports early recognition, informed evaluation, and individualized management of neurologic complications in sepsis while also emphasizing the long-term impact of brain health.

Van de Louw, Andry; Thompson, Garrett

doi: 10.1177/08850666261421885pmid: 41697835

BackgroundHematological malignancies expose patients to lactic acidosis, either type A (mostly due to sepsis) or B (malignancy related). As information is scarce about lactic acidosis in this population, we aimed to describe its characteristics and impact on outcome.MethodsRetrospective chart review of all patients with hematological malignancies admitted to the ICU and with lactates measured between 2008 and 2018. Hyperlactatemia and lactic acidosis were defined by blood lactate levels ≥ 2 and 4 mmol/L respectively.ResultsHyperlactatemia and lactic acidosis were present in 60% and 30% of the 666 patients included respectively and lactic acidosis was independently associated with hospital mortality (OR 2.00, 95% CI 1.02-3.87, p = 0.04). A cluster analysis in the whole population revealed 3 clusters of patients with prognostic implication: a first cluster was characterized by diverse hematological malignancies, low incidence of hyperlactatemia, low requirements for vital organ support and low mortality (14%). A second cluster included patients mostly with type A lactic acidosis due to septic shock or cardiac arrest, with severe multiorgan failure and extremely high mortality (87%), whereas the third cluster included patients frequently with lymphoma and no obvious cause for lactic acidosis and was characterized by less severe multiorgan failure and intermediate mortality (40%). Patients with type B lactic acidosis were more frequently male, with lymphoma, they had less severe hyperlactatemia, acidosis, acute kidney injury, they required less vital organ support and had lower mortality rate than type A acidosis (32.4% vs 77.2%, p < 0.001).ConclusionsLactic acidosis was frequent in ICU patients with hematological malignancies and associated with mortality. As a surrogate for type B acidosis, patients with no obvious cause for lactic acidosis and no vasopressor requirements had lower mortality than type A lactic acidosis.

Ren, Qingwei; Chen, Yanyan; Xu, Xinxin; Wang, Jianlong; Du, Yueting; Shi, Ying; Shao, Xuejun

doi: 10.1177/08850666261448521pmid: 42141953

BackgroundPatients with sepsis-associated liver injury (SALI) are at marked risk of delirium, a severe complication strongly linked with poor neurological outcomes. Early identification remains challenging, as existing predictive tools lack specificity for this distinct population. An interpretable machine learning (ML) model was designed and validated to enable prediction of delirium among SALI patients.MethodsDe-identified data from MIMIC-IV were retrospectively assessed in this cohort study. The dataset was randomly partitioned, with 70% assigned to model training and 30% reserved for evaluation. Independent predictors were identified through univariate analysis followed by stepwise multivariable logistic regression. Support Vector Machine (SVM), Logistic Regression (LR), Random Forest (RF), Gradient Boosting Machine (GBM), and Extreme Gradient Boosting (XGBoost) were constructed and tested regarding discrimination, calibration, and clinical usefulness. Model interpretation was performed using the Shapley Additive Explanations (SHAP) framework.ResultsAmong 1461 patients with SALI, 917 (62.8%) developed delirium. Seven independent risk factors were identified: diabetes with chronic complications, reduced SpO2, decreased hemoglobin, lower Glasgow Coma Scale (GCS) score, and treatment with continuous renal replacement therapy (CRRT), vasopressin, or mechanical ventilation. The GBM model demonstrated optimal performance, achieving an area under the receiver operating characteristic curve (AUROC) of 0.831 in the training set and 0.811 (95% CI: 0.766-0.855) in the testing set. SHAP analysis revealed that mechanical ventilation, GCS score, CRRT requirement, and hemoglobin levels were the most influential predictors, indicating that delirium risk is primarily driven by markers of multi-organ dysfunction.ConclusionsAn interpretable gradient boosting model was established and assessed for its ability to predict delirium among individuals with SALI. The model's transparency, achieved through SHAP analysis, establishes clear associations between delirium and quantifiable markers of multi-organ dysfunction. This tool enables early, individualized risk stratification, facilitating targeted preventive interventions to improve outcomes in this vulnerable population.

Lamikanra, Olaoluwatomi K.; Venigalla, Medha; Olowofeso, Abisola M.; Aneni, Ehimen C.; Osondu, Chukwuemeka U.; Otite, Fadar O.

doi: 10.1177/08850666261451793pmid: 42141948

BackgroundCoronavirus disease 2019 (COVID-19), caused by the SARS-CoV-2 virus, was first identified in late 2019 and went on to profoundly disrupt health care systems worldwide. The pandemic led to unprecedented increases in healthcare delivery costs, widespread disruption in medical supply chains, workforce instability, and a loss of typical inpatient caregiver support. These challenges affected all levels of care, from primary health services to highly specialized intensive care units (ICUs). Before vaccines were available, ICUs were overwhelmed by critically ill patients requiring mechanical ventilation, saturating capacity and straining staff.ObjectivesThis article seeks to examine the effect that COVID-19 had on ICUs globally, acknowledging its impact with an aim to identify solutions that can be used to help mitigate the overburdening of this limited resource in future pandemics.MethodsA narrative review approach was used, drawing on published literature, observational data, and institutional responses from 2020 to 2025, to analyze structural, operational, and clinical adjustments in ICU design and function.ResultsKey adaptations included physical redesigns, rapid infection-control upgrades, the use of negative pressure rooms, expansion of tele-ICU systems, and virtual family engagement strategies. These interventions were implemented to address ICU crowding, equipment shortages, and staff burnout, and helped to maintain continuity of care during surge conditions.ConclusionsThe COVID-19 pandemic demonstrated the need for ICUs to be more agile, scalable, and future-facing. Lessons learned highlight the importance of preparedness strategies that strengthen ICU resilience and support critical care delivery in future public health emergencies.

Merren, Michael P.; Feller, David; Lange, Sawyer B.; Ahmad, Sumera R.; Buda, Kevin G.; Kor, Nathan T.; Takahashi, Edwin A.; Motiei, Arashk; Ursoleo, Jacopo D’Andria; Nabzdyk, Christoph G.; Caples, Sean M.; Elmadhoun, Omar

Dumrongsukit, Sophon; Charoensri, Suranut; Mulalin, Kamonwan; Panitchote, Anupol

doi: 10.1177/08850666261423897pmid: 41706665

IntroductionElevated serum cortisol levels at the onset of septic shock have been linked to increased mortality. However, their relationship with hemodynamic recovery, particularly shock reversal, has not been well studied.MethodsWe conducted a prospective cohort study at Srinagarind Hospital, Thailand, between June 2019 and December 2021, enrolling adult patients diagnosed with septic shock in the emergency department. Serum cortisol levels and illness severity (SOFA and APACHE III scores) were assessed at diagnosis. Shock reversal was defined as vasopressor discontinuation with sustained mean arterial pressure ≥ 65 mm Hg for 24 h.ResultsOf 81 enrolled patients, 58 (71.6%) achieved shock reversal within 72 h. Higher serum cortisol levels were independently associated with a lower probability of shock reversal at 72 h (HR per 1 µg/dL increase: 0.95, 95% CI: 0.92-0.97) and with reduced likelihood of early shock control at 6 h (HR: 0.96, 95% CI: 0.93-0.99). Compared with cortisol < 18 µg/dL, levels of 18–30 µg/dL and > 30 µg/dL were associated with substantially lower probabilities of 72-h shock reversal (HR: 0.31, 95% CI: 0.15-0.64; HR: 0.17, 95% CI: 0.08-0.37, respectively). Each 10 µg/dL increase in cortisol corresponded to a 0.64-point increase in SOFA score at 72 h (95% CI: 0.28-1.0). No significant association was observed with 28-day mortality.ConclusionElevated serum cortisol at the onset of septic shock independently predicted delayed shock reversal and a lower likelihood of early shock control, but was not associated with 28-day mortality.