Current therapies for severe COVID-19, such as steroids and immunomodulators are associated with various side effects. N-acetylcysteine (NAC) has emerged as a potential adjunctive therapy with minimal side effects for patients with cytokine storm due to COVID-19. However, evidence supporting high-dose intravenous NAC in severe COVID-19 pneumonia requiring mechanical ventilation is limited.

This narrative review explores the implementation and impact of sepsis code protocols, an urgent intervention strategy designed to improve clinical outcomes in patients with sepsis. We examined the degree of implementation, activation criteria, areas of implementation, personnel involved, responses after activation, goals and targets, impact on clinical indicators, and challenges in implementation. The reviewed evidence suggests that sepsis codes can significantly reduce sepsis-related mortality and enhance early administration of treatments. However, variability in activation criteria and inconsistent application present ongoing challenges. The review considers the incorporation of newer scoring systems, such as NEWS and MEWS, and the potential integration of machine learning tools for early sepsis detection. It highlights the importance of tailoring implementation to specific healthcare contexts and the value of ongoing training to optimize sepsis response. Limitations include the ongoing controversy surrounding sepsis definitions and the need for standardized, feasible quality indicators. Future research should focus on standardizing activation criteria, improving protocol adherence, and exploring emerging technologies to enhance early sepsis detection and management. Despite challenges, sepsis codes show promise in improving patient outcomes when implemented thoughtfully and consistently across healthcare settings.

Venous obstructions and thrombosis can present diagnostic challenges due to their varied presentations and potential for significant complications if untreated. Pulse wave doppler ultrasound via identification of damping or loss of cardiac pulsatility and/ or respiratory phasicity of venous waveforms serves as a practical, noninvasive, fast, and efficient diagnostic tool for identifying venous obstructions in the presence of compressible veins beyond the point of evaluation.We present two cases demonstrating the effectiveness of pulse wave doppler ultrasound in identifying significant and life-threatening venous obstructions. The first case involves a 68-year-old male with an incidental finding of a compressible left subclavian vein showing a monophasic waveform. Further investigation revealed significant compression of the left brachiocephalic vein by an aortic arch aneurysm. The second case describes a 65-year-old male with a compressible right femoral vein but a monophasic waveform, leading to the discovery of extensive thrombosis from the iliac veins to the inferior vena cava. This series proposes to always assess cardiac pulsatility and respiratory phasicity during doppler ultrasound procedure such as thyroid ultrasounds, deep vein thrombosis (DVT) evaluations, and pre-central vein catheterizations for identifying any venous obstructions, whether they are intrinsic or extrinsic, and for reducing the risk of thromboembolic complications.

There is a considerable gap in the current evidence concerning the prevalence of superinfections among critically ill patients with SARS-CoV-2 infection in Saudi Arabia.

To assess the role of blood gas analysis as an auxiliary tool for detecting and predicting the progression of COVID-19 in patients.

Dexmedetomidine (DEX) is a highly favored sedative agent in critically ill patients owing to its anxiolytic and analgesic properties, lower risk of delirium, and minimal respiratory depression. Additionally, DEX exhibits anti-inflammatory properties, which have prompted its use in managing COVID-19 patients to mitigate cytokine storm and multi-organ dysfunction. Thus, this study aims to evaluate the safety and effectiveness of DEX use in critically ill patients with COVID-19. This multicenter, retrospective cohort study included adult patients with confirmed COVID-19 who were admitted to the ICUs and did not require invasive mechanical ventilation (MV). Patients were categorized into two groups based on receiving DEX use within 72 h of ICU admission. The primary outcome was respiratory failure requiring invasive MV; other outcomes were considered secondary. A total of 155 patients were included in the study after propensity matching. DEX did not reduce respiratory failure requiring invasive MV (HR 0.66; 95% CI (0.28, 1.53),  = .33). However, the time for invasive MV was statistically significantly shorter in the DEX group compared with the control group (beta coefficient (95%CI): - 1.05 (-2.03, -0.07),  = .03). In contrast, ICU and hospital Length of stay (LOS) were not statistically significant compared to the control group (beta coefficient 0.04 (95% CI -0.29, 0.38),  = .80, and beta coefficient - 0.03 (95% CI -0.33, 0.26),  = .81, respectively). In addition, the 30-day and in-hospital mortality rates were similar between the two groups (HR 1.1; 95% CI 0.97, 1.20,  = .14, and HR 1.01; 95% CI 0.95, 1.06,  = .90, respectively). Dexmedetomidine did not appear to lower the risk of respiratory failure necessitating invasive mechanical ventilation in critically ill patients. However, the mean time for invasive mechanical ventilation was shorter in the DEX group. Future interventional studies are required to confirm our findings.

The prone position is often used for patients with adult respiratory distress syndrome and specific surgical postures. When performing venous cannulation in this position, it is important to have a structured review to introduce the available major veins and ultrasound-guided procedure. In this review, we discuss the techniques of ultrasound-guided cannulation and provide insights into various aspects, including the anatomical locations of veins, vein sizes, placement techniques, surrounding structures at risk, and reported experiences with catheter placements. Eight major veins can be accessed in the prone position: the internal jugular vein, external jugular vein, brachiocephalic vein, basilic vein, mid-thigh femoral vein, popliteal vein, posterior tibial vein, and small saphenous vein. To minimize the risk of venous thromboembolism, the ratio of catheter diameter to vessel diameter should be less than 0.67. The review also presents the minimal requirement of venous diameter for different catheters in a tabulated form. For larger veins, real-time ultrasound guidance with the long-axis view/in-plane technique is suggested, while for smaller vessels, the short-axis view/out-of-plane technique is recommended. The review includes sonographic illustrations of the two techniques and surrounding arteries and nerves for the eight major veins. The aim of this review is to help clinicians assess the eight major veins and safely insert various types of catheters for patients in the prone position.

The impact of methylene blue (MB) on critical patient outcomes, including overall mortality, hemodynamic stability, and organ function has been inconsistently described across studies. This study aims to evaluate the efficacy of MB therapy in adult patients with septic shock in the intensive care unit (ICU).

Delirium frequently occurs in the acute phase of sepsis and is associated with increased ICU and hospital length of stay, duration of mechanical ventilation, and higher mortality rates. We utilized the Near-Infrared Spectroscopy monitor to measure and compare the regional cerebral oxygen saturation in mechanically ventilated patients of sepsis receiving either dexmedetomidine or propofol sedation and assessed the association between delirium and regional cerebral oxygen saturation.

During the COVID-19 pandemic, treatment strategies evolved rapidly. The RECOVERY trial established corticosteroids as the standard care for reducing mortality in COVID-19 patients. However, some critical care clinicians began using doses higher than those recommended in RECOVERY.

Thousands of critically ill patients every year in the United States receive tracheostomy and gastrostomy procedures. Recent research has investigated the benefits of a combined team approach to these procedures, with associated decreases in length of stay (LOS) and hospital costs. This study's objective was to determine if implementing a bedside percutaneous tracheostomy and percutaneous ultrasound gastrostomy (PUG) team would reduce LOS and hospital costs. This retrospective chart review compares the impact of implementing an ICU bedside percutaneous tracheostomy and PUG service team to the hospital's previous workflow (ie, pre-implementation). Inclusion criteria were adult patients with Ventilator Dependent Respiratory Failure (VDRF), a clinical indication for both procedures while admitted to the ICU and received both tracheostomy and gastrostomy procedures while admitted to the hospital. Pre- and post-implementation groups were compared across patients' demographics, clinical characteristics, and outcomes. ICU LOS, hospital LOS and total hospital costs were the primary outcome measures. A total of 101 adult critically ill patients were included in the analysis; 49 patients were in the pre-implementation group and 52 patients in the post-implementation group (ie, PUG group). Patients in the PUG group had a significantly shorter mean ICU LOS and hospital LOS, 10.9- and 14.7-day reductions respectively (p = 0.010, p = 0.006). PUG group patients also had a significant reduction in total hospital costs, a per patient cost savings of $34 778 (p = 0.043). This study supports implementing a bedside percutaneous tracheostomy and PUG team to reduce LOS and total hospital costs in patients with VDRF.

Ventilator-associated pneumonia (VAP) is a common and serious nosocomial infection affecting critically ill patients undergoing mechanical ventilation. This study investigated the prevalence of multidrug-resistant (MDR) organisms in VAP, the VAP rate, and the outcomes associated with MDR-VAP.

The goal of this study was to identify changes in cognitive and functional capacity after hospital discharge in those infected with COVID-19 who were admitted to the ICU.

The cardiovascular component of the Sequential Organ Failure Assessment (SOFA) score does not correspond with contemporary clinical practice in sepsis or identify impaired cardiac function. Our aim was to develop a modified cardiovascular SOFA component that reflects cardiac dysfunction and improves the SOFA score's 30-day mortality discrimination.

Extubation Advisor (EA) is a novel software tool that generates a synoptic report for each Spontaneous Breathing Trial (SBT) conducted to inform extubation decision-making.

The systematic review and meta-analysis performed by Kang et al about the effect of extended prone positioning in intubated COVID-19 patients with ARDS presents valuable findings on the effectiveness and safety of extended prone positioning, but also raises several concerns which require clarifications. The inclusion of observational studies without any control group, the use of crude rather than adjusted estimates in key variables from observational studies, an error in data extraction from randomized clinical trials, and the employment of odds ratios rather than risk ratios, may mislead interpretations of the aforementioned intervention.

Arrhythmias, common after pediatric cardiac surgery, are associated with increased morbidity and mortality. Atrial epicardial wires (AEW) improve diagnostic accuracy but have variable pacing and sensing properties based on their location. Even so, there are no longitudinal prospective pediatric studies examining ideal placement of AEW. This multicenter study compared atrial amplitudes, pacing sensitivities and thresholds via AEW placed at Bachmann's Bundle (BB) and the interatrial groove near the right pulmonary veins (IGRPV) versus the surgeons' standard locations. An AtriAmp system was used to obtain an atrial ECG to calculate atrial and ventricular amplitude from atrial electrograms on the bedside monitor. Sensitivities and thresholds via a temporary pacemaker were documented. ANOVA tests with repeated measures and post-hoc pairwise comparisons were performed to compare variables within the first 24-h postoperative hours. Mixed effects linear regression models were employed to examine daily trends. In the first 24-h following cardiac surgery, AEW at BB and IGRPV showed significantly larger atrial amplitudes than the surgeons' standard locations. In addition, there was a negative trend in atrial ECG amplitude in all AEW from postoperative days 0 to 1; however, subsequent days showed a positive mean change in atrial amplitude with largest increase seen at BB. Atrial sensing as measured by the temporary pacemaker had statistically greater atrial signal amplitude from the BB-IGRPV set in both polarities (ie, with the BB as the - or + electrode pair) as compared to the surgeons' standard locations. No difference in atrial thresholds (mA) were noted in the immediate postoperative period or over time, with a relatively low atrial threshold at all sites. Standardization of AEW at Bachmann's Bundle can yield largest atrial amplitudes by atrial ECG and highest atrial sensing parameters without compromising atrial thresholds.

Develop an inpatient predictive model of parental post-traumatic stress (PTS) following their child's care in the Pediatric Intensive Care Unit (PICU). Prospective observational cohort. Two tertiary care children's hospitals with mixed medical/surgical/cardiac PICUs. Parents of patients admitted to the PICU. None. Preadmission and admission data from 169 parents of 129 children who completed follow up screening for parental post-traumatic stress symptoms at 3-9 months post PICU discharge were utilized to develop a predictive model estimating the risk of parental PTS 3-9 months after hospital discharge. The parent cohort was predominantly female (63%), partnered (75%), and working (70%). Child median age was 3 years (IQR 0.36-9.04), and more than half had chronic illnesses (56%) or previous ICU admissions (64%). Thirty-five percent (60/169) of parents met criteria for PTS (>9 on the Post-traumatic Stress Disorder Symptom Scale-Interview). The machine learning model (XGBoost) predicted subjects with parental PTS with 76.7% accuracy, had a sensitivity of 0.83 (95% CI 0.586, 0.964), a specificity of 0.72 (95% CI 0.506, 0.879), a precision of 0.682 (95% CI 0.451, 0.861) and number needed to evaluate of 1.47 (95% CI 1.16, 1.98). The area under the receiver operating curve was 0.78 (95% CI 0.64, 0.92). The most important predictive pre-admission and admission variables were determined using the Local Interpretable Model-Agnostic Explanation, which identified seven variables used 100% of the time. Composite variables of parental history of mental illness and traumatic experiences were most important. A machine learning model using parent risk factors predicted subsequent PTS at 3-9 months following their child's PICU discharge with an accuracy of 76.7% and number needed to evaluate of 1.47. This performance is sufficient to identify parents who are at risk during hospitalization, making inpatient and acute post admission mitigation initiatives possible.

High-risk acute pulmonary embolism (PE) is associated with significant mortality and may require emergency endotracheal intubation and mechanical ventilation. Intubation and ventilation are thought to exacerbate cardiorespiratory instability. Our purpose was to conduct a systematic literature review to identify studies investigating peri-intubation events in acute PE.

Myoclonus after anoxic brain injury is a marker of significant cerebral injury. Absent cortical signal (N20) on somatosensory evoked potentials (SSEPs) after cardiac arrest is a reliable predictor of poor neurological recovery when combined with an overall clinical picture consistent with severe widespread neurological injury. We evaluated a clinical question of if SSEP result could be predicted from other clinical and neurodiagnostic testing results in patients with post-anoxic myoclonus.