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ABSTRACT Objective: To estimate the number of intensive care unit hospitalization days that could have been managed at an intermediate care unit level and to assess the impact of intermediate care unit-eligible patients on intensive care unit-free days, hospital-free days, and nursing workload. Methods: This single-center, prospective cohort study included all patients admitted to the intensive care unit of an academic hospital between June 1, 2021, and May 31, 2022. All adult (> 18 years of age) patients with an intensive care unit stay exceeding 24 hours were eligible for inclusion. Data from a total of 1,547 patients were analysed. Daily, intensive care unit head nurses identified patients eligible for intermediate care unit management based on predefined criteria. Nursing workload was quantified using the Nursing Activities Score, and 16,478 Nursing Activities Score assessments, recorded at the end of each nursing shift, were collected. Results: A total of 1,457 intensive care unit hospitalization days (16.7% of the total) were classified as eligible for intermediate care unit-level management. An increase in cumulative intermediate care unit days was significantly associated with fewer intensive care unit - and hospital-free days (adjusted incidence rate ratio = 0.98 [95%CI 0.97 - 0.99] for both). A strong negative correlation was observed between the monthly proportion of intermediate care unit-eligible intensive care unit days and the intensive care unit occupancy rate (R = −0.703, p = 0.011). By shift, the median Nursing Activities Score for intensive care unit patients was 72.4 [59.6 - 87.5] compared to 63.5 [52.6 - 72.8] for intermediate care unit-eligible patients in the morning, 71.5 [58.1 - 86.6] versus 56 [47.8 - 66.1] in the afternoon and 66.1 [53.5 - 81.1] versus 53.9 [45 - 64.7] during night shifts (p < 0.001 for all). Conclusion: This study highlights the potential impact of early identification of intermediate care unit-eligible patients on optimizing the use of intensive care unit beds and improving the organization of patient care. A lower Nursing Activities Score might help select patients for intermediate care unit care, supporting the clinical relevance of such a score in the daily assessment of intensive care unit patients.

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ABSTRACT Objective: To assess the prevalence and evolution of acid-base disturbances at intensive care unit admission and throughout hospitalization and their association with intensive care unit mortality. Methods: A retrospective epidemiological study was conducted, analyzing consecutive patients admitted to a single intensive care unit. Results: Metabolic acidosis, either isolated or combined with other disturbances, was the most prevalent disorder (58.0%), followed by respiratory alkalosis (37.6%), respiratory acidosis (25.7%), and metabolic alkalosis (12.8%). Multivariate analysis demonstrated that metabolic alkalosis combined with respiratory alkalosis was independently associated with reduced mortality (OR 0.427, 95%CI 0.194 - 0.869). Higher standard base excess at intensive care unit admission was correlated with lower mortality (OR 0.973, 95%CI 0.956 - 0.990). Maximum pCO2 variation during hospitalization showed no significant association with mortality. However, greater standard base excess improvement was independently linked to reduced mortality in patients with intensive care unit stays exceeding 5 days. Additionally, disease severity markers and younger age were predictive of metabolic acidosis both at admission and during hospitalization. Conclusion: Metabolic acidosis was the most common acid-base disorder at intensive care unit admission, with lower standard base excess levels associated with increased mortality. Standard base excess improvement during prolonged intensive care unit stays correlated with improved survival. Disease severity indicators were predictive of metabolic acidosis upon admission and throughout hospitalization.

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ABSTRACT Background: Intensive care unit registries, which aim to improve the quality of intensive care unit care through benchmarking and quality improvement initiatives, are active worldwide, with considerable dishomogeneity. We aimed to map core datasets, additional variables, and research activities of these registries. Methods: A cross-sectional survey was disseminated to registry leads between October 2023 and June 2024. The survey was structured into four main topics: registry characteristics and coverage, core dataset features, additional modules, and registry-enabled research. Results: Leads of 34/42 national registries responded (response rate 81%), covering 3,337 intensive care units, with a larger representation from South America. Systematized nomenclature of medicine, clinical terms, and customized categorical classifications were the main nomenclatures used. All registries except one employed a severity of illness score/risk prediction model. The SOFA score was reported by 88% of registries. Organ support measures were often recorded, including mechanical ventilation (97%), vasopressor administration (86%) and renal replacement therapy (86%). Three out of four intensive care unit registries coded interventions such as intubations, intravenous lines and tracheostomies. Additional datasets differed, with many use cases for nosocomial infection burden, bed availability and staffing resources. Over half of intensive care unit registries had current structured quality improvement initiatives. Registry-enabled observational research was reported in 46% of registries, while interventional studies were reported in only 22%. Conclusion: Over three thousand intensive care units in 35 countries participate in an intensive care unit registry. Despite heterogeneity in coding systems, risk models, and additional datasets, we identify several areas of convergence that may inform a future shared core dataset. There is potential for further intensive care unit registry-based research, particularly interventional.

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ABSTRACT Objective: To evaluate the impact of noninvasive ventilation versus bag-valve-mask ventilation preoxygenation on safety and efficacy outcomes. Methods: PubMed, Embase, and Cochrane databases were searched for randomized controlled trials that compared preoxygenation using noninvasive ventilation and bag-valve-mask ventilation. The reported outcomes were all-cause mortality; hypoxemia during intubation; and regurgitation. We perform frequentist and Bayesian analysis. Heterogeneity was examined with I2 statistics. Statistical analysis was done using RStudio and Review Manager. Results: We included 3 randomized controlled trials with 1,555 patients, of whom 771 (49.6%) received preoxygenation with noninvasive ventilation (intervention group). Hypoxemia during intubation was significantly lower in the noninvasive ventilation compared to the bag-valve-mask ventilation group in frequentist with a pooled log RR of −0.94 (log RR −0.94; 95%CI −1.61 − −0.28) and Bayesian pooled log risk ratio of −0.32 (log RR −0.32; 95% credible interval −0.91 − 0.40). Regurgitation was a safety outcome that did not present a difference between the groups in the frequentist or Bayesian models, with log RR −0.50 (log RR −0.50; 95% credible interval −2.09 − 1.01). There was no significant difference between groups in all-cause mortality and other secondary outcomes. Conclusion: Preoxygenation with noninvasive ventilation significantly reduces the risk of hypoxemia during emergency intubation compared to bag-valve-mask ventilation. However, there were no significant differences in all-cause mortality or regurgitation rates.

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ABSTRACT Objective: To implement and evaluate a new inpatient flow process designed to reduce overnight transfers, decrease Emergency Department length of stay, and improve overall hospital throughput. Methods: A two-phase quality improvement initiative was conducted using the DMAIC (Define, Measure, Analyze, Improve, Control) framework. In Phase 1, "flow beds" were introduced to minimize overnight patient transfers and enhance staff and patient experiences. Phase 2 implemented an early morning transfer process from the trauma and neurosurgery intensive care unit to the trauma and neurosurgery inpatient ward, aligning intensive care unit capacity with anticipated daily demand. The effectiveness of the interventions was assessed using a before-and-after study design. Results: Flow beds were successfully created in over 85% of eligible cases, reducing overnight transfers to alternate units by more than 50%. Emergency Department length of stay and decision-to-admit times improved by 25% and 43%, respectively, at the 90th percentile (p < 0.05). Total inpatient length of stay decreased by 11% (approximately 1 day). In Phase 2, early trauma and neurosurgery intensive care unit discharges occurred in 50% of cases, eliminating surgical cancellations due to intensive care unit bed shortages during the study period. Conclusion: Proactive inpatient flow strategies focused on demand-capacity alignment significantly improved Emergency Department and inpatient metrics, while reducing intensive care unit-related surgical delays.

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ABSTRACT Objective: To longitudinally evaluate muscle strength and mobility in an intensive care unit and identify factors associated with muscle weakness at intensive care unit discharge. Methods: A retrospective cohort study was conducted with patients who had their muscle strength measured at some point during their intensive care unit stay. Muscle strength was assessed using the Medical Research Council score, and measurements were taken at two points: as soon as medically possible (first assessment) and discharge. Mobility was assessed using the Functional Status Score for the intensive care unit scale, which includes bed transfer and locomotion activities. These activities were evaluated at three points: previous status, as soon as medically possible (first assessment), and discharge. Results: The change in muscle strength in the sample of 1,310 patients between the assessment at discharge [56 (48 - 60)] and the first assessment [54 (48 - 60)] was significant (p value < 0.001). When comparing mobility levels, a significant difference (p < 0.001) was observed between the time prior to hospitalization [35 (34 - 35)], the first assessment [28 (20 - 33)], and discharge [29 (21 - 35)]. Factors associated with muscle weakness were length of stay in the intensive care unit [OR 1.16 (1.06 - 1.28); p = 0.002]; use of sedation [OR 3.8 (1.27 - 11.16); p = 0.016] and muscle strength score at the first assessment [OR 0.84 (0.79 - 0.90); p = 0.001]. Conclusion: Muscle strength and mobility increased from the first assessment to discharge. Prospective studies are needed to explore the trends observed in this study.

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ABSTRACT Objective: To evaluate the influence of weaning vasopressors – norepinephrine or vasopressin - on deleterious effects; the main objective was to evaluate the incidence of hypotension. Methods: We performed a systematic review and meta-analysis of 11 studies - 2 randomized controlled trials and 9 observational studies - involving 2,280 patients in whom norepinephrine (n = 1,254) or vasopressin (n = 1,026) was withdrawn first to compare the risk of hypotension and other adverse effects. Results: Hypotension occurred in 33.4% (420/1,254) of patients in the Norepinephrine Group and in 52,4% (538/1,026) of patients in the Vasopressin Group. There was no difference between groups regarding the incidence of hypotension: OR 0.43 (95%CI 0.18 - 1.03). The subgroup analysis of observational studies suggests a lower incidence of hypotension when norepinephrine is weaned first (OR 0.26; 95%CI 0.13 - 0.53), with high heterogeneity between studies (I2 = 88%; p < 0.01). On the other hand, the subgroup of randomized controlled trials indicates a higher incidence of hypotension when norepinephrine is weaned first (OR 4.04; 95%CI 1.24 - 13.15; I2 = 65%, p = 0.09). The weaning strategy was not associated with other outcomes, including intensive care unit length of stay, hospital length of stay, time on vasopressors, arrhythmias, renal injury, or SOFA. Conclusion: No differences in hypotension incidence were observed when weaning was initiated with either norepinephrine or vasopressin. However, the high heterogeneity observed across studies warrants caution in drawing definitive conclusions.

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ABSTRACT Objective: To characterize real-world high-flow nasal cannula use and outcomes. Methods: A retrospective observational study using an electronic health record registry of all adult patients in a five-hospital system between 2017 - 2025. We identified all high-flow nasal cannula episodes, defined as periods of high-flow nasal cannula use containing breaks no longer than 6 hours. We describe key measurements, including high-flow nasal cannula episode duration, intubation rates, and death or hospice discharge rates; secondary outcomes included intensive care unit admission, lengths of stay, and discharge location. We used adjusted hierarchical logistic regression to evaluate variation across hospitals. Results: 28,269 high-flow nasal cannula episodes from 17,519 individual patients over 19,313 hospitalizations were identified. Average high-flow nasal cannula use increased from 176 episodes/month in 2017 to 269 episodes/month by 2024 (p < 0.001). Median episode duration was 13.9 [interquartile range 4.3 - 36] hours, 24.5% of episodes were followed by intubation, and 29.3% by death or hospice discharge; 83.6% of high-flow nasal cannula use was escalation respiratory therapy, with the remainder used within 24 hours of extubation. Illness severity, admitting service, hospital, and unit type were associated with the odds of intubation and the duration of high-flow nasal cannula episodes; 16% of the variation in mortality and 20% of the variation in intubation were attributable to hospital-level variation. Conclusion: High-flow nasal cannula is used in multiple hospital settings and contexts. The use of high-flow nasal cannula has increased between 2017 and 2025. Outcomes of high-flow nasal cannula use are influenced by both patient characteristics and the contexts in which it is used.

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ABSTRACT Objective To compare the effects of four positive end-expiratory pressure titration methods on respiratory system compliance over the first 3 days of mechanical ventilation and to analyze the agreement between derived positive end-expiratory pressure and compliance values among these methods immediately after randomization. Methods Single-center, randomized study acute respiratory distress syndrome patients were assigned to one of four groups based on positive end-expiratory pressure titration methods: electrical impedance tomography, transpulmonary pressure measured via an esophageal catheter, the best compliance approach with daily positive end-expiratory pressure titration, and a control group using a low positive end-expiratory pressure/ fraction of inspired oxygen table with adjustments as necessary. The primary outcome was mean respiratory system compliance over the first 3 days of mechanical ventilation. Immediately post-randomization, the best positive end-expiratory pressure according to each method was assessed for every patient, and within-patient agreement of titrated positive end-expiratory pressure and compliance for pairs of methods was calculated with the Bland-Altman method. Results Forty-nine patients participated. Compared to control, the mean difference in compliance was 0.03mL/cmH2O (95%CI -2.74 to 2.8) in the Electrical impedance tomography Group; 1.90mL/cmH2O (95%CI -0.98 to 4.78) in the Catheter Group, and 1.42mL/cmH2O (95%CI -1.35 to 4.19) in the best compliance group. Within-patient agreement of titrated positive end-expiratory pressure and compliance was poor, with 95% limits of agreement ranging from -9.3 to 9cmH2O for positive end-expiratory pressure and from -8.5 to 11.4mL/cmH2O for compliance. Conclusion No significant differences in mean respiratory system compliance were found among positive end-expiratory pressure titration methods compared to control. The agreement between titrated positive end-expiratory pressure and respiratory system compliance using different methods was low.

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ABSTRACT Objective To determine the optimal PaO2:FiO2 threshold in the first 24 hours of intensive care unit admission, and its associated discriminatory capacity, for prognostication of mortality among critically ill patients. Methods This bi-national registry included adult patients admitted to intensive care units in Australia and New Zealand from January-2018 to December-2022. The primary outcome was hospital mortality. Acute hypoxic respiratory failure was defined as PaO2:FiO2 of < 300 using the worst PaO2:FiO2 within the first 24 hours of intensive care unit admission. The unadjusted association between PaO2:FiO2 and hospital mortality was evaluated using restricted cubic splines with four knots to allow for continuous, non-linear associations. To determine the optimal threshold of the PaO2:FiO2 for predicting hospital mortality, Youden’s method was used to identify the maximum sum of sensitivity and specificity. The area under the receiver operating characteristic curve and Youden’s J-index were calculated to compare pre-specified subgroups. Results Among the 662,612 included patients, acute hypoxic respiratory failure was not present in 324,761 (49%) patients, mild in 181,499 (27%) patients, moderate in 128,277 (19%) patients, and severe in 28,125 (4%) patients. The hospital mortality rates, respectively, were 4.9% (15,797/324,761), 7.9% (14,291/181,499), 14% (18,247/128,277), and 31% (8,717/28,125). The association between PaO2:FiO2 and hospital mortality was non-linear with an inflection point at PaO2:FiO2 = 200. The area under the ROC curve was 0.677 (95%CI 0.675 - 0.679) with an optimum PaO2:FiO2 threshold of 230. (Youden’s J-index of 0.267, sensitivity 56.1% and specificity 70.6%). The area under the ROC curve was 0.627 for patients who required invasive ventilation during their intensive care unit stay, compared with 0.698 for those who did not. Conclusion The optimal PaO2:FiO2 threshold for predicting hospital mortality was 230. PaO2:FiO2 has low discriminatory capacity in predicting hospital mortality among intensive care unit patients.

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ABSTRACT Objective To identify medications associated with changes in serum potassium concentrations in critically ill neonates. Methods A prospective cohort study was conducted between March 2023 and March 2024 in the neonatal intensive care units of a public maternity hospital in Brazil. Neonates admitted for over 24 hours and receiving at least one medication were included. Serum potassium levels were monitored daily, and associations with medications were assessed using mixed-effects linear regression models. Medications used to correct potassium levels were excluded from the analysis. Results Among 336 neonates included, the mean gestational age was 33.8 ± 4.0 weeks, and the mean serum potassium level during the first 30 days was 4.4 ± 0.3mEq/L. Hypokalemia was more frequent than hyperkalemia (3.1 versus 0.7 cases per 100 neonates). Dopamine (β = 0.584; p = 0.003) and norepinephrine (β = 0.811; p = 0.001) were associated with increased potassium levels, while dobutamine (β = -0.308; p = 0.029) was linked to reduced levels. Norepinephrine use was associated with the highest observed potassium concentrations (6.2 ± 2.1mEq/L). Conclusion Catecholamines significantly influence serum potassium in neonates. Norepinephrine poses the most significant risk of hyperkalemia, whereas dobutamine tends to lower potassium levels. These findings emphasize the importance of potassium monitoring during vasoactive therapy in neonatal intensive care units.

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ABSTRACT Objective: To compare the performance of the standard equation (SAPS 3-SE) and a customized version (SAPS 3-Custom) of the Simplified Acute Physiology Score 3 in a contemporary cohort of Brazilian and Uruguayan intensive care unit patients. Methods: We conducted a retrospective cohort study of 262,198 adults admitted to 177 intensive care units between 2022 and 2023. Discrimination was assessed using the area under the Receiver Operating Characteristic curve (AUROC), and calibration by comparing predicted and observed mortality in calibration curves. Results: Of patients 70% were medical, and 21% were scheduled for surgery; mean SAPS 3 was 46.6 ± 16.0. Median intensive care unit and hospital stays were 3 (1 - 5) and 8 (4 - 16) days, respectively. Intensive care unit mortality was 10.6% and hospital mortality was 16.4%. Predicted mortality was 19.0% for SAPS 3-SE and 16.6% for SAPS 3-Custom. Both models had excellent discrimination (AUROC = 0.841). SAPS 3-SE overestimated mortality across all risk deciles, whereas SAPS 3-Custom achieved uniform agreement between predicted and observed values. Standardized mortality rates were 0.86 (95%CI 0.85 - 0.87) for SAPS 3-SE and 0.98 (0.98 - 0.99) for SAPS 3-Custom; standardized resource use rates were 0.90 (0.90 - 0.91) and 0.98 (0.97 - 0.98), respectively. At the intensive care unit level, SAPS 3-Custom produced standardized mortality rates (0.95 [0.77 - 1.17]) and standardized resource use rates (0.97 [0.82 - 1.23]) distributions centered around 1.0, unlike SAPS 3-SE, which yielded lower values. Findings were consistent for medical and surgical subgroups. Conclusion: In this large, contemporary cohort, SAPS 3-Custom demonstrated superior calibration and accuracy over SAPS 3-SE, supporting its use for performance evaluation and benchmarking in intensive care units in Brazil and Uruguay.

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ABSTRACT Objective Mechanical ventilation is an essential tool in the management of acute respiratory failure. Extubation is a critical event in the clinical course of patients, yet it may fail even in those who successfully complete a spontaneous breathing trial. This study aimed to evaluate which ventilator settings and monitoring variables are associated with extubation failure. Methods This was a retrospective, multicenter cohort study, including patients from July 2021 to December 2022 across five intensive care units in Argentina. Adult patients (≥ 18 years old) who received at least 48 hours of mechanical ventilation and underwent an extubation were included. A multivariable logistic regression was performed with extubation failure - defined as reintubation or death within 7 days post-extubation– as the outcome variable. The analysis was adjusted for APACHE II score, type of spontaneous breathing trial, use of non-invasive ventilatory support after extubation, and COVID-19 as a reason for mechanical ventilation. Results A total of 516 patients were analyzed, with an extubation failure rate of 35.8%. Oxygenation, measured by the oxygen saturation/fraction of inspired oxygen ratio prior to extubation was associated with a protective effect (OR 0.99, 95%CI 0.993 - 0.997) while higher positive end-expiratory pressure, fraction of inspired oxygen, and peak pressure showed a significant association with extubation failure (OR 1.26, 95%CI 1.09 - 1.45; OR 1.04, 95%CI 1.01 - 1.07; OR 1.04, 95%CI 1,003 - 1.07 respectively). Additionally, patients who failed had a higher incidence of delirium on the day of extubation and greater use of neuromuscular blocking agents during their intensive care unit stay. Conclusion In critically ill patients undergoing mechanical ventilation, ventilator settings, monitoring parameters, and oxygenation status at the time of extubation may influence the likelihood of success. Better oxygenation appears protective, whereas elevated positive end-expiratory pressure and fraction of inspired oxygen may indicate increased vulnerability to extubation failure.

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ABSTRACT Objective: To determine the sensitivity and specificity of lung ultrasound in diagnosing respiratory pathologies in children on respiratory support in the pediatric intensive care unit, compared to chest X-ray and clinical diagnosis. Methods: A cross-sectional study was conducted on children aged 1 month to 18 years admitted to the pediatric intensive care unit and requiring respiratory support from June 2018 to February 2019. Lung ultrasound was performed within 24 hours of chest X-ray by a trained sonographer using standardized protocols. Lung ultrasound and chest X-ray were interpreted independently by blinded physicians. A Receiver Operating Characteristic curve was generated to assess lung ultrasound diagnostic performance using chest X-ray as the gold standard. Results: A total of 220 lung ultrasounds were performed on 117 patients, with 195 (88.6%) examinations completed. Lung ultrasound and chest X-ray were reported normal in 24 (10.9%) and 21 (9.5%) studies, respectively, with no pneumothorax detected. Overall, lung ultrasound had a sensitivity of 89.95% and specificity of 19.05% compared to chest X-ray. Sensitivity and specificity for pneumonia and pediatric acute respiratory distress syndrome were 62.8% and 44.8%, and 50% and 96%, respectively. Using clinical diagnosis as reference, sensitivity and specificity for pneumonia and pediatric acute respiratory distress syndrome were 59.8% and 54.3%, and 72.7% and 95.7%, respectively. Agreement between chest X-ray and lung ultrasound was poor (k = 0.085), though concordance among lung ultrasound providers was high (k = 0.869). Agreement for lung ultrasound and pediatric acute respiratory distress syndrome was highest (k = 0.632) compared with clinical diagnosis. Receiver Operating Curve analysis showed that lung ultrasound showed poor diagnostic accuracy compared to chest X-ray (AUC 0.54). Conclusion: Lung ultrasound is feasible in low-resource pediatric intensive care unit settings but shows limited diagnostic accuracy compared to chest X-ray.

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ABSTRACT Objective: To evaluate the current practices of hemodynamic monitoring in sepsis and septic shock in Brazilian pediatric intensive care units. Methods: A multicenter, cross-sectional study using an electronic survey. Results: An electronic survey was responded to in three rounds (1 week each), and responses from 77 pediatric intensive care units in 26 states of Brazil were collected. Point-of-care cardiac ultrasound was the method of choice for fluid responsiveness evaluation in septic children in 61% pediatric intensive care units; 78% pediatric intensive care units had enough arterial line monitors available to every bed, but only 57% use invasive arterial blood pressure monitoring for every patient diagnosed with septic shock; 22% use invasive arterial blood pressure monitoring just for refractory shock patients. To guide initiation/titration of inotropes and vasoactive agents, 70% pediatric intensive care units said their decision is based on clinical assessment; 20% use point-of-care cardiac ultrasound to aid vasoactive agent choice; 88% pediatric intensive care units use Lactate trend, and 35% measure central/mixed venous saturation in patients with septic shock. Conclusion: Differences between international guidelines and practice in Brazilian pediatric intensive care units regarding hemodynamic monitoring in pediatric sepsis were identified. These differences may arise for several reasons; recognizing them is crucial to making appropriate changes and adjusting valuable guidelines to make them more feasible for low- and middle-income countries.

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ABSTRACT Objective: To conduct a systematic review and meta-analysis with trial sequential analysis to compare the efficacy of high-flow nasal cannula versus noninvasive ventilation in preventing reintubation, post-extubation respiratory failure, mortality, and length of stay in intensive care unit and hospital in patients at high risk of extubation failure. Methods: A comprehensive literature search was conducted across ten databases: MEDLINE®/PubMed®, Web of Science, SciELO, Embase, Scopus, the Cochrane Central Register of Controlled Trials, the International Clinical Trials Registry Platform, Google Scholar, GreyNet International, and OpenGrey. The primary outcome was reintubation. Secondary outcomes included post-extubation respiratory failure, intensive care unit and hospital mortality, as well as intensive care unit and hospital length of stay. Results: Ten randomized controlled trials comprising 1,697 patients were included. There were no significant differences between high-flow nasal cannula and non-invasive ventilation in reintubation (RR = 1.00; 95%CI 0.92 - 1.09; p = 0.92; I2 = 65.0%), intensive care unit mortality (RR 1.03; 95%CI 1.00 - 1.07; p = 0.08; I2 = 28.0%), hospital mortality (RR 1.02; 95%CI 0.99 - 1.06; p = 0.13; I2 = 0%), intensive care unit length of stay (mean difference: -0.51 days; 95%CI -1.85 to 0.82; I2 = 63.0%), and hospital length of stay (mean difference: 0.80 days; 95%CI -1.72 to 3.32; I2 = 47.0%). High-flow nasal cannula showed a non-significant trend toward lower post-extubation respiratory failure and intensive care unit mortality in patients ventilated > 5 days. Conclusion: In adult patients at high risk of extubation failure, the use of high-flow nasal cannula is not associated with significant differences in reintubation rates, intensive care unit or hospital mortality, or intensive care unit or hospital length of stay compared with noninvasive ventilation. PROSPERO register: CRD420251104362

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ABSTRACT Objective: To describe clinical outcomes and identify predictors of death and complications in children undergoing tracheostomy at a public referral hospital in the Federal District. Methods: A retrospective cohort study including 123 children (zero to 14 years) who underwent tracheostomy between 2017 and 2021. Patients under exclusive palliative care, those lost to follow-up, or with a tracheostomy performed prior to 2017 were excluded. Follow-up spanned from the procedure date until decannulation, death, or the study end (August 2, 2025), with a mean duration of 26.9 months. Data on demographics, clinical indicators, complications, and outcomes were analyzed using descriptive statistics, survival analysis (Kaplan-Meier), binary logistic regression, and Poisson regression. Results: The majority were infants (58.5%) and male (53.7%). Upper airway obstruction was the predominant indication (41.5%). The overall mortality was 39%, and septic shock was the leading cause (16.7%). Complications occurred in 52% of cases, most notably tracheitis (42.2%) and accidental decannulation (32.8%). Multivariate analysis identified the following as independent predictors of death: tracheitis (OR 4.79; 95%CI 2.15 - 10.68; p = 0.001), mechanical ventilation dependence (OR 3.43; 95%CI 1.52 - 7.74; p = 0.003), and accidental decannulation (OR 2.44; 95%CI 1.05 - 5.66; p = 0.037). Poisson regression showed that longer tracheostomy use time (IRR 1.137; p = 0.008) and complex chronic diseases (IRR 1.573; p = 0.011) were associated with higher complication rates. Conclusion: Tracheostomized children in this public hospital setting experience high morbidity and mortality, influenced significantly by modifiable factors such as infection, ventilator dependence, and decannulation events.

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ABSTRACT Objective To provide an overview of the evidence comparing the use of balanced crystalloids and normal saline in critically ill patients. Methods A comprehensive literature search was conducted in PubMed®, Embase, and Cochrane databases through July 2024. Systematic reviews with meta-analyses comparing balanced crystalloids versus normal saline in critically ill patients were included. The methodological quality of the included reviews was assessed using the AMSTAR-2 tool. Results Fourteen systematic reviews published between 2018 and 2024 met the inclusion criteria. Key clinical outcomes evaluated included mortality, acute kidney injury, and initiation of renal replacement therapy. Patient subgroups analyzed encompassed sepsis, trauma, hypovolemia, traumatic brain injury, postoperative status (cardiac and non-cardiac), and elderly populations. The methodological quality assessment of reviews using AMSTAR-2 revealed that most reviews had critical weaknesses in one or more domains. Quality appraisal revealed that one review had no critical domain weaknesses, while 13 reviews exhibited limitations in these domains. Evidence synthesis indicated a small benefit of balanced crystalloids compared to normal saline, especially among patients with sepsis and those without traumatic brain injury. Conclusion This overview of systematic reviews suggests a small clinical advantage of balanced crystalloids over normal saline in critically ill patients, particularly in subgroups such as those with sepsis.

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ABSTRACT Objective To evaluate the efficacy of monotherapy versus combination therapy in the treatment of carbapenem-resistant Acinetobacter baumannii infections. Methods A retrospective observational study was conducted in two tertiary hospitals in Brazil from 2018 to 2022. Patients diagnosed with bloodstream infections or ventilator-associated pneumonia caused by carbapenem-resistant Acinetobacter baumannii were included. Data on demographics, clinical characteristics, antimicrobial regimens, and outcomes were collected. Statistical analyses, including multivariate logistic regression, were performed to identify predictors of mortality. Results Among 123 patients (median age: 61 years), 86.2% were treated in the intensive care unit, 28-day mortality was 59,3%, and the overall mortality was 73.2%. Combination therapy was more frequently used (75.6%) and typically involved polymyxin-based regimens (71.5%). Sulbactam-containing regimens were employed in 16.3% of cases. Monotherapy was more common in ventilator-associated pneumonia (33.3%) than in bloodstream infections (14%). Mortality rates were similar between monotherapy and combination therapy (73.3% versus 73.1%; p = 0.982). In the multivariable logistic regression model, only the APACHE II score (OR = 1.12; 95%CI 1.05 - 1.21; p = 0.001) remained independently associated with mortality. Sulbactam-based therapy was not independently associated with survival (OR = 0.80; 95%CI 0.22 - 2.85; p = 0.725). Conclusion Our findings suggest that neither monotherapy nor combination therapy is associated with lower mortality in this cohort of carbapenem-resistant Acinetobacter baumannii infections, likely due to the severity of the baseline illness. Further prospective studies are needed to confirm these results and refine treatment guidelines.

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ABSTRACT Objective: To investigate the association between ventilator-associated pneumonia and outcomes in mechanically ventilated nontraumatic intracerebral hemorrhage patients. Methods: Retrospective data analysis from the National Inpatient Sample database, including patients from 2008 to 2022, for adult hospitalized intracerebral hemorrhage patients on mechanical ventilation. Variables included age, sex, race, hospital location, comorbidities, indicators of intracerebral hemorrhage severity, and neurosurgical procedures. The cohort was divided into ventilator-associated pneumonia and non-ventilator-associated pneumonia groups. Propensity-score matching was applied to balance comorbidities and severity between the two groups. Binary logistic regression was used to analyze the predetermined outcomes. P value was set at 0.05. Results: Of 70,870 mechanically ventilated intracerebral hemorrhage patients, 3,183 (4.5%) developed ventilator-associated pneumonia. Intracerebral hemorrhage patients with ventilator-associated pneumonia were younger (59 [49 - 69] versus 65 [54 - 76]), more frequently male (62.3% versus 54.3%), and more frequently black (27.4% versus 21.2%), p < 0.001 for all. Ventilator-associated pneumonia patients had a higher rate of cerebral edema (50.7% versus 37%), brain compression (32.5% versus 27.3%), obstructive hydrocephalus (36.1% versus 24.7%), and neurosurgical procedures, both external ventricular drain (38.2% versus 20.2%) and hematoma evacuation (13.8% versus 8.6%), p < 0.001 for all. Time from presentation to intubation was longer in ventilator-associated pneumonia (days; 0 [0 - 3] versus 0 [0 - 1], p < 0.001). After 1:1 propensity-score matching, binary logistic regression revealed that ventilator-associated pneumonia remained independently associated with prolonged length of hospital stay (OR = 1.56, 95%CI 1.3 - 1.82; p < 0.01), higher hospitalization cost (OR = 1.47, 95%CI 1.26 - 1.7; p < 0.01) and higher odds of unfavorable discharge disposition (OR = 1.26, 95%CI 1.06 - 1.49; p = 0.01). Conclusion: Ventilator-associated pneumonia significantly complicates the care of mechanically ventilated intracerebral hemorrhage patients, increasing the healthcare resource utilization, prolonging length of stay, and being associated with worse short-term functional outcomes.

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ABSTRACT Objective: To assess the incidence of cardiac surgery-associated acute kidney injury and to evaluate secondary outcomes, including 30-day mortality, prolonged mechanical ventilation, kidney replacement therapy, renal recovery, and length-of-stay metrics. Methods: This retrospective observational study analyzed routinely recorded data from a single multi-hospital healthcare system, including all adult cardiac surgery intensive care unit patients between July 1st, 2021, and June 30, 2022. Cardiac surgery-associated acute kidney injury was stratified according to the KDIGO guidelines using serum creatinine. Urine output criteria were incorporated when available. Results: Cardiac surgery-associated acute kidney injury of any stage occurred in 16.7% of patients (stage 1 - 13.6%, stage 2 - 1.8%, and stage 3 - 1.3%). Thirty-day mortality had wide confidence intervals, with odds ratios of 20.8 (95%CI 3.8 - 114) and 93.6 (95%CI 23.4 - 375) for acute kidney injury stages 2 and 3, respectively, compared with stage 0. A total of 27.5% (52/189) of patients with cardiac surgery-associated acute kidney injury did not meet the strict definition of renal recovery at discharge. Median intensive care unit length of stay, average time on mechanical, and time to discharge were significantly longer in patients with cardiac surgery-associated acute kidney injury (p < 0.001). Conclusion: Cardiac surgery-associated acute kidney injury is a common postoperative complication associated with substantially increased mortality, prolonged ventilation, longer length of stay, and reduced renal recovery. These findings underscore the clinical importance of early identification, risk stratification, and perioperative management strategies to mitigate harm from acute kidney injury.

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ABSTRACT Objective: To describe the requirements for modeling the tele-ICU platform, its development, the process, software, and hardware technologies employed. We also present its performance based on a proof-of-concept in a remote intensive care unit environment. Methods: This multicenter, prospective implementation study was conducted in three Level III Intensive Care Units in distinct Brazilian regions between June 2021 and December 2022. The INTEGRARE®, an Internet of Medical Things-based hardware/software architecture enabling agnostic integration of multiparameter monitors and mechanical ventilators, was deployed to provide continuous high-frequency telemetry, a unified analytical dashboard, and synchronous audiovisual communication for tele-round sessions. The proof-of-concept comprised continuous multimodal monitoring, collaborative tele-round discussions, and structured knowledge transfer. Nineteen months of multiparameter monitors and mechanical ventilators data were processed through a four-step data workflow (edge server, cloud storage, preprocessing, and analytical layer). All clinical, operational, and performance metrics were automatically generated by the platform. Results: The INTEGRARE® enabled integration of multiparameter monitors and mechanical ventilator devices across 30 intensive care unit beds, generating over 2 billion data points with a median acquisition frequency of ~1 second and cross-device synchronization under 5 seconds. A total of 361 patients were monitored (7,235 intensive care unit-days), with a median intensive care unit stay of 14 days and 11 days on mechanical ventilators among ventilated patients. Tele-round sessions completed 484 hours, with a median of 3 hours and 39 minutes per intensive care unit per week. The platform supported real-time visualization and retrospective review of physiological curves, ventilator mechanics, laboratory results, and imaging within a unified dashboard. High adherence to tele-round routines was observed across multidisciplinary teams, who spontaneously incorporated multimodal telemetry into case discussions. Immediate bedside impact was common, including rapid identification and correction of patients’ ventilator asynchrony. Conclusion: The Tele-UTI Conectada model provides a technical infrastructure that supports standardization, situation awareness, and collaborative clinical decision-making by integrating real-time telemetry with synchronous audiovisual interaction across heterogeneous intensive care units. Multidisciplinary teams successfully adopted the platform and routinely used it to conduct structured case discussions.

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ABSTRACT Objective: To determine the prevalence of oral alterations among critical patients within the first 48 hours of intensive care unit admission, and their association with hospital-acquired pneumonia, bloodstream infections, and sepsis. Methods: This prospective cohort study was conducted from March 2018 to December 2021 in a Brazilian neurology intensive care unit. A single dental surgeon assessed oral conditions with follow-up until hospital discharge. Logistic regression analyzed the association between oral alterations and outcomes (hospital-acquired pneumonia, bloodstream infections, and sepsis), adjusting for confounders. Results: We enrolled 248 patients (55.6% male; mean age, 67.2 years), of whom 97.6% had oral abnormalities. The most common were visible dental plaque (61.7%), gingival inflammation (60.9%), and five or more missing teeth (49.2%). Carious teeth were linked to pneumonia (OR 1.10; 95%CI 1.00 - 1.20; p = 0.047). Destroyed teeth (OR 1.12; 95%CI 1.02 - 1.23; p = 0.02) and visible plaque (OR 1.08; 95%CI 1.00 - 1.17; p = 0.04) were associated with bloodstream infections. No factors were linked to sepsis. Conclusion: Most patients exhibited oral alterations upon admission to the intensive care unit. Carious teeth may increase pneumonia risk, while destroyed teeth and visible plaque may raise bloodstream infection risk.

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ABSTRACT Objective Cardiac surgery-associated acute kidney injury is a common and serious complication of cardiac surgery. Albumin solution is a commonly administered fluid in cardiac surgery patients; the role of albumin in preventing cardiac surgery-associated acute kidney injury is unclear. The objective of this systematic review and meta-analysis was to evaluate the impact of perioperative albumin compared with other fluid regimens on the risk of acute kidney injury in cardiac surgical patients undergoing cardiopulmonary bypass. Methods A systematic search was performed of MEDLINE®, Embase, CINAHL, and Cochrane Central Register of Controlled Trials databases, and the Australian New Zealand Clinical Trials Registry, ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform, and ISRCTN registries. Randomized trials of adult patients undergoing on-bypass cardiac surgery comparing albumin-containing solutions with any other fluid regimen given perioperatively were included. Trials comparing fluids used only for bypass priming were excluded. Data extraction, risk of bias, and certainty of evidence were assessed in duplicate by independent reviewers. A Bayesian framework was the primary statistical approach, with a secondary frequentist approach. The primary outcome was perioperative acute kidney injury, defined as the period from surgery until hospital discharge. Secondary outcomes were all-cause mortality at longest follow-up, intensive care unit length of stay, hospital length of stay, proportion of patients requiring renal replacement therapy postoperatively, duration of mechanical ventilation postoperatively, and duration of vasopressor support postoperatively. Results Fourteen randomized trials, including 3,304 adults, were included in the analysis. Seven trials contributed data to the primary outcome. Four trials had an overall low risk of bias across all domains and outcomes. The pooled estimated risk ratio for acute kidney injury with albumin solutions was 1.09 (95% credible interval 0.86 - 1.34, tau = 0.12; I2 = 31.5%), with a 18.3% posterior probability of reduced acute kidney injury. There were no significant subgroup effects or differences in secondary outcomes. Conclusion Among patients undergoing on-bypass cardiac surgery, the use of albumin solutions is unlikely to reduce the risk of acute kidney injury. Other interventions need to be considered for this condition.

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ABSTRACT Objective Critical illness profoundly alters the gut microbiome, yet its temporal evolution and clinical relevance remain unclear. This systematic review aimed to synthesize evidence from longitudinal sequencing studies describing gut microbiome changes in critically ill adults and their association with clinical outcomes. Methods We systematically searched MEDLINE®, Scopus, and Cochrane CENTRAL from inception to May 2025 for longitudinal observational studies analyzing gastrointestinal samples by sequencing in adult critically ill patients at ≥ 2 times points. Extracted data included study and patient characteristics, as well as microbiome outcomes, including alpha and beta diversity metrics and taxonomic abundance profiles. Due to heterogeneity, we undertook a structured descriptive synthesis: alpha diversity results were grouped by trajectory and compared across intensive care unit populations; beta diversity findings were tabulated and narratively synthesized; and reported associations with mortality and multidrug-resistant organism colonization were summarized narratively. Risk of bias was assessed with RoBANS 2, and certainty of evidence with GRADE. Results Thirty-six studies comprising 2,067 critically ill adults were included. Most used 16S rRNA sequencing targeting the V4 region. A decline in alpha diversity was reported in 18 out of 31 studies, while 8 found no change and 4 mixed patterns. Beta diversity shifts over time were reported in 11 studies. Taxonomic analyses consistently revealed the expansion of opportunistic taxa such as Enterococcus, Klebsiella, and other Enterobacteriaceae, alongside the depletion of obligate anaerobes, including Blautia, Coprococcus, and Faecalibacterium. Early low diversity and pathogen-dominated microbiomes were associated with increased mortality. Associations with multidrug-resistant organism colonization were inconsistent. Certainty of evidence (GRADE) for all outcomes was rated very low due to heterogeneity and imprecision. Conclusion Longitudinal sequencing studies demonstrate progressive loss of microbial diversity and enrichment of pathogenic taxa during critical illness. These shifts, particularly Enterococcus and Klebsiella overgrowth, correlate with adverse outcomes and may reflect the combined effects of antibiotics, disease severity, and critical care interventions. Standardized sampling, sequencing, and reporting protocols are needed to enable meta-analytic synthesis and guide microbiome-targeted interventions in the intensive care unit.

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ABSTRACT Objective: To evaluate the effect of spontaneous ventilation duration during invasive mechanical ventilation on diaphragm protection, defined as maintaining a diaphragm thickness fraction between 15% and 30%. Methods: The present prospective, observational study enrolled one hundred adult patients with mild to moderate acute respiratory distress syndrome requiring invasive mechanical ventilation. After recruitment, the mode of invasive mechanical ventilation was recorded, and the diaphragm thickness fraction was measured daily until patients were extubated or died. Based on the total mechanical ventilation duration, patients were divided into three groups: Group 1 (3 - 7 days), Group 2 (8 - 15 days), and Group 3 (> 15 days). The patient's total spontaneous ventilation duration (more than 12 hours of ventilation on spontaneous mode comprised one day of spontaneous ventilation) was recorded in days during the mechanical ventilation stay. The duration of diaphragm protective ventilation was defined as the number of days during which the diaphragm thickness fraction remained between 15% and 30%. The primary outcome was to assess the correlation between spontaneous ventilation duration and diaphragm protective ventilation duration. The secondary outcome was the impact of spontaneous ventilation duration on total mechanical ventilation duration, intensive care unit length of stay, and survival. Results: There was a strong positive correlation between spontaneous ventilation duration and diaphragm protective ventilation duration as well as between spontaneous ventilation duration% and diaphragm protective ventilation duration% in the study population as well as in all three groups (r = 0.96, 0.91, 0.97 and 0.89, respectively; p value < 0.001) and (r = 0.88, 0.86, 0.96 and 0.90, respectively; p value < 0.001), respectively. The crude mortality rate was significantly lower with longer spontaneous ventilation duration (p value < 0.001), and a similar trend was observed in the age, SOFA score, and total mechanical ventilation duration-adjusted mortality. Conclusion: In patients with acute respiratory distress syndrome requiring invasive mechanical ventilation, encouragement of spontaneous ventilation provides diaphragm protection as evidenced by a strong positive correlation between spontaneous ventilation duration and diaphragm protective ventilation duration. In addition, patients with longer spontaneous ventilation duration may experience improved survival. Further research is needed to confirm the findings of the present study.

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ABSTRACT Objective: We aimed to assess the effect of a short period of invasive mechanical ventilation after a successful spontaneous breathing trial, compared with immediate extubation, on the risk of reintubation within 48 hours. Methods: We conducted a systematic review and meta-analysis of randomized clinical trials comparing a short period of invasive mechanical ventilation following a successful spontaneous breathing trial versus immediate extubation. We searched PubMed®, Cochrane Central, Embase, Scopus, and Web of Science. Pairs of reviewers independently screened studies, extracted data, and assessed risk of bias with the Cochrane Risk of Bias tool 2.0. The primary outcome was reintubation within 48 hours after randomization. Data were pooled using a Hartung-Knapp-Sidik-Jonkman random-effects model. Trial sequential analysis was performed to determine whether the accumulated evidence was sufficient for definitive conclusions. Certainty of evidence was assessed using the GRADE approach. Secondary outcomes were reintubation or death within 7 days after extubation, intensive care unit and hospital length of stay, in-hospital mortality, and ventilator-free days up to day 28. Results: Our search identified 1,473 unique records, of which 4 randomized clinical trials (n = 1,071 patients) were eligible. The pooled risk ratio for reintubation within 48 hours in patients receiving a short period of invasive mechanical ventilation after a successful spontaneous breathing trial, compared with immediate extubation, was 0.48 (95% confidence interval 0.22 - 1.07; p = 0.06; I2 = 41.6%). Trial sequential analysis confirmed that the current evidence base is underpowered for definitive conclusions. The evidence was rated as low due to serious inconsistency and imprecision. No significant differences were observed for any of the secondary outcomes. Conclusions: Among critically ill adults, a short period of invasive mechanical ventilation after a successful spontaneous breathing trial did not significantly reduce the risk of extubation failure within 48 hours compared with immediate extubation (low-certainty evidence). Further adequately powered trials are needed to clarify the clinical efficacy of this intervention.

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ABSTRACT Objective: To evaluate the effectiveness of the ramp position over the sniffing position for endotracheal intubation in obese patients. Methods: We performed a systematic review and meta-analysis comparing ramping with sniffing position for endotracheal intubation in obese patients. We systematically searched PubMed®, Embase, and the Cochrane Library. Primary outcomes included Cormack-Lehane grading and first-pass success. We applied a random-effects model to pool relative risks and mean differences with 95% confidence intervals. Statistical analyses were performed using R 4.4.2. Results: We included four randomized controlled trials and two cohort studies. Of the 938 participants, 54.16% (508) were intubated in the ramp position. Ramping did not improve first pass success (RR 1.07; 95%CI 0.98 - 1.16; p = 0.14; I2 = 61.6%), Cormack-Lehane grades 1 - 2 (RR 0.99; 95%CI 0.97 - 1.02; p = 0.61; I2 = 0%), or Cormack-Lehane grades 3 - 4 (RR 1.94; 95%CI 0.86 - 4.37; p = 0.11; I2 = 0%). Although ramping decreased mean tube insertion and intubation time, these results did not persist in the sensitivity analyses. However, ramping decreased the number of intubation attempts in the operating room subgroup (RR 0.33; 95%CI 0.19 - 0.58; p < 0.001; I2 = 0%) and video-laryngoscopy subgroup (RR 0.33; 95%CI 0.15 - 0.70; p = 0.02; I2 = 0%). Conclusion: Our results suggest that ramping offers first-pass success and laryngeal view rates comparable to those of the sniffing position. In terms of secondary outcomes, patients in the operating room or those intubated with a video-laryngoscopy may benefit from decreased intubation attempts. Future studies with standardized definitions are required to evaluate these findings in different settings. PROSPERO register: CRD42025638839

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ABSTRACT Objective: To examine the association between socioeconomic status and patient outcomes following unplanned intensive care unit admissions in Australia, using national data linked across public databases. Methods: We conducted a national retrospective cohort study of all adult unplanned intensive care unit admissions in Australia between January 2017 and December 2019, using data from the Australian and New Zealand Intensive Care Society Adult Patient Database. Socioeconomic status was determined using the Australian Bureau of Statistics’ 2016 Index of Relative Socio-Economic Advantage and Disadvantage (IRSAD), linked by patient postcode. The primary outcome was hospital mortality, adjusted for severity of illness, remoteness, year of admission, and intensive care unit, using a mixed-effects logistic regression model. Results: A total of 245,867 intensive care unit admissions were included. Patients in the most disadvantaged quartile were less likely to be treated in tertiary or private hospitals. Still, there was otherwise no significant difference in demographic profile, intensive care unit interventions received, or reasons for admission. In the multivariate analysis, there were no significant differences in adjusted hospital mortality across IRSAD deciles (p = 0.3). Discussion: In this national study, socioeconomic status was not associated with hospital mortality after adjustment for illness severity and hospital factors. These findings suggest that structural health system features, such as universal access to critical care in Australia, may mitigate the adverse effects of socioeconomic disadvantage among unplanned intensive care unit outcomes observed in other health systems. Further research is warranted to explore the pathways linking socioeconomic status, health access, and intensive care unit admission characteristics.

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ABSTRACT Objective: To examine how acute kidney injury is represented and reported in randomized controlled trials of acute respiratory distress syndrome with mortality as the primary endpoint. Methods: This descriptive systematic review included parallel-arm randomized controlled trials enrolling adult patients with acute respiratory distress syndrome, defined by American-European Consensus Conference or Berlin criteria, in which mortality was the primary outcome. The protocol was prospectively registered in PROSPERO (CRD420251043094). Searches were conducted in PubMed®/MEDLINE®, Embase, and Scopus for studies published between January 1st, 2005, and April 10, 2025. Two reviewers independently screened studies and extracted data by consensus. Data extraction focused on acute kidney injury reporting, use of standardized definitions, serum creatinine, renal replacement therapy, fluid balance, and kidney-related subgroup analyses. Results: Twenty-seven randomized controlled trials met inclusion criteria. None applied standardized acute kidney injury definitions such as KDIGO, AKIN, or RIFLE. Serum creatinine was reported in two trials and renal replacement therapy in four, without details on timing or criteria. Organ dysfunction scores were commonly reported, but renal subscores were not specified. Fluid balance was reported in five trials but was not included in the adjusted analyses. No study performed mortality analyses stratified by acute kidney injury or baseline kidney function. Conclusion: Acute kidney injury is inconsistently represented in randomized trials of acute respiratory distress syndrome evaluating mortality. This inconsistency limits the interpretation of extrapulmonary organ dysfunction. Recognizing the multisystem nature of critical illness may improve the clinical relevance of future trial designs.

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ABSTRACT Objective: To identify research gaps and propose strategies for enhancing the quality and efficiency of critical care services globally. Methods: We will explore and analyze metrics, models, and methodologies for efficiency assessment and benchmarking in intensive care units, including both static and longitudinal approaches. For so, we will comprehensively search three electronic databases (Scopus, Web of Science, and Embase) using predefined keywords combined with Boolean operators. The search will target peer-reviewed studies without time frame restrictions. Duplicates will be removed, and two reviewers will independently assess the eligibility of articles based on predefined inclusion and exclusion criteria. Relevant data will be extracted and organized thematically using a standardized form aligned with PRISMA guidelines. The extracted data will include a study of characteristics, methodologies, and outcomes, enabling structured mapping and synthesis of existing evidence. This review does not require ethical approval. Results: The findings will be disseminated through open-access journal publications and national and international conferences presentations. The results will also be shared with key stakeholders, including healthcare professionals, policymakers, and researchers, to foster discussions on improving intensive care unit performance. Conclusion: This review will synthesize available evidence on ICU efficiency assessment, contributing to standardization efforts and guiding future research priorities aimed at strengthening critical care management and benchmarking practices worldwide.

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ABSTRACT Background and aims: There are conflicting data regarding the use of propofol in the intensive care unit. The present study aims to explore the propofol dose-response relationship in the context of associations with clinical outcomes. Here we present the data collection and analysis procedures. Methods and analysis: The International Nutrition Survey (www.criticalcarenutrition.com) contains data from 785 medical, surgical, or trauma intensive care units. This survey also includes data on daily mechanical ventilation and propofol use, along with the associated propofol-related energy intake. Of the 21,100 adult patients, we will analyze those who spent at least 48 hours in the intensive care unit. Data collection will include patient characteristics, propofol parameters, use of mechanical ventilation, severity of illness at intensive care unit admission, and time to discharge alive or in-hospital death. In addition to the duration of propofol therapy (days), propofol-associated fat intake will be used as a surrogate for propofol dose. Statistical analyses will use multistate models and piece-wise exponential additive mixed models to examine associations between propofol use (including associated fat intake) and outcomes, while adjusting for numerous confounders and accounting for mechanical ventilation. Ethics and dissemination: Institutional ethics approval was granted by the Health Sciences Research Ethics Board at Queen's University, Kingston, Ontario (file number 6004791). Informed patient consent was not required due to the nature of this study. Procedures were conducted in accordance with the ethical standards of the institutional or regional committee for human experimentation and the Helsinki Declaration of 1975.

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ABSTRACT Objective: To describe the analytical objectives and procedures of the Tele-Rehab MV Trial prior to database lock. Methods: The Tele-Rehab MV Trial is a cluster stepped-wedge randomized clinical trial comparing a telemedicine-based quality improvement program focused on disability prevention and rehabilitation strategies with usual care. The intervention is implemented during the patient's intensive care unit stay, continued through ward admission, and extends up to 2 months post-hospital discharge. The trial targets adult patients with acute hypoxemic respiratory failure requiring invasive mechanical ventilation, in whom SARS-CoV-2 infection is part of the differential diagnosis. The protocol was approved by the Research Ethics Committee of the coordinating center and by the ethics committees of each of the 20 participating intensive care units, in accordance with Brazilian regulations. The primary outcome is health-related quality of life, assessed 90 days after hospital discharge using the EuroQol 5-Dimension 3-Level (EQ-5D-3L) scale. Secondary outcomes include 30-day rehospitalization, all-cause mortality, anxiety, depression, cognitive impairment, new disabilities in instrumental activities of daily living, and return to work or study 90 days after discharge. This report outlines the primary statistical procedures to be used for evaluating results and conducting sensitivity analyses. Conclusion: We anticipate that this reporting approach will minimize analysis bias and enhance the interpretation of the Tele-Rehab MV Trial results.

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ABSTRACT Objective: To describe the study protocol and statistical analysis plan that will be used to evaluate whether methylene blue reduces interventions aimed at controlling hypotension during renal replacement therapy as compared to usual care. Methods: BLUE is a randomized, multicenter, open-label trial. Patients with high risk of hypotension during renal replacement therapy will be randomized to receive either methylene blue infusion at a dose of 1mg/kg as a bolus, followed by continuous infusion of 0.1mg/kg of body weight in a total of 200mL of saline solution throughout the dialysis session, or to usual care. The usual care group will not receive any intervention. A total of 260 patients is expected to be randomized in a 1:1 ratio. Results: The primary outcome will be a composite of any of the following events: (1) initiation of vasopressor therapy or an increase of at least 20% from baseline dose; (2) interruption of the renal replacement therapy session; or (3) interruption of fluid removal at the request of the attending physician at any point during the session. Secondary outcomes include the occurrence of hypotension during the hemodialysis session, the maximum vasopressor dose within the first 24 hours, intensive care unit mortality, and in-hospital mortality. Conclusion: The BLUE study will provide evidence on the role of methylene blue in preventing hypotension during renal replacement therapy.

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ABSTRACT Background: Pre-eclampsia is a multisystemic disorder characterized by varied degrees of placental malperfusion. It is estimated to affect 3 - 5% of pregnancies globally, accounting for up to 15% of maternal morbidity and mortality. Solutions to improve outcomes for pre-eclampsia and eclampsia are increasingly focused on improving recognition and on timely, effective treatment, notably through the implementation of treatment guidelines and protocols. To date adoption of guidelines in clinical practice have been variable, with the lowest adoption observed in settings where the policies and evidence did not originate. This study is designed to address known barriers by proposing a stakeholder-led, co-designed protocol adaptation process, followed by an evaluation of the effectiveness of a multi-implementation strategy (education, audit and feedback, and the use of champions) to support practice change. Methods: Using co-design, a protocol for managing pre-eclampsia with severe features and eclampsia will be adapted and implemented. The process will involve three stages; protocol selection and adaptation, implementation of the clinical protocol and evaluation of the process. The primary outcome will be implementation success, assessed across three domains of the Reach, Effectiveness -Adoption Implementation and Maintenance (RE-AIM) framework: Fidelity, Reach, and Adoption. Secondary outcomes, including intervention effectiveness and clinical safety endpoints, will also be evaluated. Analysis: The individual components of the RE-AIM framework will be computed as percentages. A composite threshold of 80% will be deemed success. The secondary outcome variables will be compared to the pre-implementation period.

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ABSTRACT Critical illness disrupts hemostasis through tightly linked inflammatory, endothelial, platelet, and coagulation pathways collectively described as immunothrombosis. These mechanisms are not sex-neutral. Biological sex and gender-related factors influence baseline coagulation profiles, vascular function, fibrinolysis, and platelet reactivity, and may therefore modify thrombotic and bleeding phenotypes observed in the intensive care unit. This short review summarizes current evidence on sex-associated differences in hemostatic biology and their clinical implications in critical illness. It outlines priorities for sex-stratified research to support more precise hemostatic management in the intensive care unit.

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ABSTRACT In the critically ill, different thrombotic phenotypes exist. In situ thrombosis differs from the classical embolus. It is characterized by cellular infiltration along the vessel wall of the smaller pulmonary arteries, as well as by a dysregulated host immune response.

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ABSTRACT Liberation from mechanical ventilation is a physiologically demanding phase of critical illness that requires coordinated recovery of respiratory muscle function, metabolic stability, and systemic resilience. Nutritional therapy plays a central role in supporting this transition. However, early aggressive caloric and protein delivery has not improved outcomes and may be detrimental. Current evidence supports a phase-adapted, individualized approach: permissive underfeeding during acute inflammation, moderate protein provision, monitoring of metabolic tolerance, and targeted correction of micronutrient deficiencies. Future research should incorporate time to successful weaning as a clinically meaningful endpoint when evaluating nutritional interventions in the intensive care unit.

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ABSTRACT Sleep disruption is nearly universal during critical illness and is increasingly linked to long-term cognitive impairment among intensive care unit survivors. Advances in neuroscience have highlighted the glymphatic system – a brain-wide perivascular network that clears metabolic waste such as β-amyloid and phosphorylated tau – as a plausible mechanism connecting sleep disturbance to adverse neurocognitive outcomes. Glymphatic transport is highly state-dependent, functioning optimally during slow-wave sleep and diminishing with wakefulness or fragmented sleep. This invited review synthesizes preclinical and human evidence showing that sleep fragmentation and loss of slow-wave sleep impair cerebrospinal fluid–interstitial fluid exchange, promote accumulation and spread of tau and other neurotoxic proteins, and may accelerate neurodegenerative trajectories. We discuss how commonly used sedatives may induce unconsciousness without reproducing the coordinated neuromodulatory and neurovascular conditions of natural slow-wave sleep, creating "pseudo-sleep" that may fail to support metabolic clearance. We propose glymphatic dysfunction as an integrative pathway linking intensive care unit sleep disruption, inflammation, and sedative exposure to persistent deficits in memory, attention, and executive function after critical illness.

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ABSTRACT Intracranial pressure monitoring is a cornerstone in neurocritical care, particularly for patients with acute brain injury. Historically, management has focused on absolute intracranial pressure thresholds, but a paradigm shift is underway towards dynamic assessment of intracranial compliance through intracranial pressure waveform analysis. This short review synthesizes recent advancements in understanding intracranial compliance pathophysiology, explores sophisticated invasive and non-invasive monitoring techniques, and discusses their evolving clinical implications. We highlighted how parameters derived from intracranial pressure waveforms, such as the P2/P1 ratio, pulse shape index, and mean pulse amplitude, provide granular insights into the brain compensatory reserve and cerebrovascular autoregulation. Integrating these new pathophysiological insights with advanced monitoring tools holds immense potential to refine clinical decision-making, enabling more proactive, personalized interventions to improve outcomes for patients with acute brain injury.

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ABSTRACT Use of surveys in clinical research allows investigators to explore stakeholders’ perspectives, measure implementation of interventions, and inform future decision-making. Surveys are versatile and accessible, but they require methodological rigor to yield adequate results. Their development involves a sequence of decisions that influence both data quality and interpretability - from defining objectives and selecting a sample to designing the questionnaire and choosing the method of administration. Questionnaires must balance clarity with precision, capturing relevant constructs without overburdening respondents. In many cases, frameworks such as Knowledge, Attitude, and Practice questionnaires are employed to structure questions and explore relationships between what individuals know, believe, and do. Online platforms increase the ability to disseminate surveys to a broader, more diverse target population and to improve data-collection workflows. Beyond the technical aspects, using surveys for clinical research faces practical challenges, such as low response rates and variability in engagement across formats. Addressing these issues requires planning and the use of strategies to encourage participation without compromising data quality. This review offers a practical overview intended to guide researchers in designing and conducting survey studies in clinical research.

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ABSTRACT The Brazilian government's minimum requirements for intensive care unit design date back to 2002 and conflict with decades of scientific evidence that emphasize the environment's impact on patient healing and health care professionals’ performance and errors, jeopardizing patient, family member, and intensive care clinician outcomes. Using guidelines from the United States and Indian Society of Critical Care Medicine, the European Society of Intensive Care Medicine and the College of Intensive Care Medicine of Australia and New Zealand as comparators, this review showcase how Brazilian minimum requirements for intensive care unit design misalign with that scientific evidence, laying the groundwork for the development of evidence-based health policies by the national intensive care medicine society and government institutions. Five domains of intensive care unit design were addressed: patient visibility, bedside workspace, lighting, bedroom layout, and greenery and outdoor facilities. Under each domain, evidence is presented indicating that current national standards for intensive care unit design are associated with negative outcomes for patients, family members, and healthcare professionals, such as decreased safety for both patients and healthcare providers, delayed recovery, and increased work-related stress, absenteeism, and human errors. Therefore, updating Brazilian minimum requirements for intensive care unit design is an urgent and necessary step to improve critical care outcomes for patients, family members, and intensive care unit staff.

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ABSTRACT Introduction: The neonatal intensive care unit employs advanced technologies to manage critical conditions. Electrical impedance tomography is a noninvasive, radiation-free imaging technique that provides real-time monitoring of pulmonary ventilation. The literature on electrical impedance tomography in the neonatal population is scattered and heterogeneous, justifying a scoping review. Objective: To map and synthesize the available evidence on the applicability of electrical impedance tomography in neonates receiving respiratory support in the neonatal intensive care unit. Methods: This protocol follows the steps described by Arksey and O’Malley as well as the recommendations of PRISMA-ScR and the Joanna Briggs Institute Manual for scoping reviews. The following databases will be used to guide searches: PubMed®, Embase, CINAHL, Web of Science, and Cochrane, with no date restrictions, in English, Spanish, and Portuguese. Two independent reviewers will screen, extract data, and assess the quality of eligible studies. Ethics and dissemination: Ethics approval is not required for this protocol and scoping review, as the study will rely exclusively on data from previously published research that has already obtained ethical approval. The results will be disseminated in a peer-reviewed scientific journal.

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ABSTRACT Incident dysnatremia has been reported amongst varied intensive care unit disease populations and is associated with worse clinical outcomes, but less is known about the impacts of dynamic changes in serum sodium during intensive care unit admission. The primary objective of this study was to conduct a scoping review of the published literature on patient outcomes associated with dynamic changes in serum sodium in critically ill adults, to inform future research priorities. A scoping review was conducted according to the Joanna Briggs Institute method. PubMed®, Embase, CINAHL, Scopus, and Web of Science databases were searched for relevant articles on sodium "change", "trajectory", "fluctuation", or "variability" in adult patients managed in the intensive care unit. Seventeen articles were extracted; seven involved patients with subarachnoid hemorrhage in the intensive care unit, and ten involved mixed or other specific primary diagnoses requiring intensive care unit admission. In subarachnoid hemorrhage, higher magnitudes of serum sodium change, independent of incident dysnatremia, are associated with greater mortality and delayed cerebral ischemia. A similar association between the magnitude of serum sodium change and mortality is observed in other intensive care unit disease populations. There is limited literature on dynamic changes in serum sodium in intensive care unit populations, but current evidence suggests that greater magnitude is associated with higher mortality and morbidity across multiple intensive care unit disease populations. Current observational literature is insufficient to establish causal links between dysnatremia and worse patient outcomes.