PURPOSE OF REVIEW:For three decades, the Sequential Organ Failure Assessment (SOFA) score has been central to critical care, offering a simple, reproducible measure of organ dysfunction. Since the original score [Sequential Organ Failure Assessment-1 (SOFA-1)] [1], advances in organ support, drugs, and monitoring, and an ageing, comorbid population have reshaped practice and rendered several tools outdated. This prompted an international initiative to modernize SOFA while preserving its core strengths: simplicity, reproducibility, feasibility across diverse settings, and longitudinal assessment of organ dysfunction. RECENT FINDINGS:SOFA-2 was developed through a modified Delphi process with 60 international experts and dedicated methodology and validation committees. Expert consensus, systematic reviews, and analyses of multinational databases (high-income, middle-income, and lower-middle-income systems) established its face, content, and predictive validity. The six original organ systems were retained; the gastrointestinal and immune domains were examined but not included because current datasets did not support them. SOFA-2 keeps the architecture of SOFA-1 while updating definitions, reflecting contemporary therapies, and standardizing missing-data handling and the scoring of acute-on-chronic dysfunction. SUMMARY:SOFA-2 is an evolution rather than a reinvention. It must now be tested in the real-world - within definitions such as Sepsis-3, across its derived variables (admission, maximum, delta, discharge), and in varied settings, including low-income and middle-income countries.
Purpose of review To provide a practical, physiology-driven framework for advanced hemodynamic monitoring in patients with acute heart failure (AHF) and cardiogenic shock, highlighting and supporting clinicians in integrating monitoring tools into an individualized bedside approach. Recent findings Cardiogenic shock is increasingly recognized as a heterogeneous syndrome involving not only impaired cardiac output, but also systemic inflammation, vasoplegia, tissue hypoperfusion and multiorgan dysfunction. Recent studies have emphasized phenotype-based approaches for both diagnosis and treatment, integrating clinical evaluation, echocardiography, invasive hemodynamics and tissue perfusion markers. Machine learning derived phenotypes have further identified cardiorenal and cardiometabolic profiles associated with distinct prognostic implications. Critical care echocardiography has a central role for rapid diagnosis and serial reassessment, while transpulmonary thermodilution and pulmonary artery catheterization provide complementary information to echocardiography in refractory or complex cases. Summary Hemodynamic monitoring in AHF and cardiogenic shock should rely on individualized, multimodal and dynamic integration of clinical examination, biomarkers, echocardiography and invasive monitoring. The main goals are to define the underlying phenotype, assess congestion and tissue hypoperfusion, and evaluate treatment response. Echocardiography remains the cornerstone of bedside assessment, whereas invasive monitoring should be reserved for selected high-risk patients with persistent or complex shock.
Purpose of review This review aims to provide a summary of recent updates in resuscitation and vasopressor strategies for septic shock, as well as advancements in precision therapy. Recent findings Septic shock results from a dysregulated host response to infection and remains a significant cause of global morbidity and mortality. While standard care of septic shock remains protocolized due to improved outcomes with timely antibiotic and fluid administration, recent data have informed a more nuanced, individualized approach to sepsis management. Increasing evidence suggests that septic shock results from dynamic phases of immune dysregulation that may provide targets for precision therapy and data from large clinical trials have informed a complementary approach to fluid and vasopressor administration, rather than a fixed, fluid-centric approach. Results additionally suggest improved outcomes with integration of multimodal perfusion targets, as well as an individualized approach to invasive hemodynamic monitoring and endpoints of resuscitation, such as capillary refill time and mean arterial perfusion pressure targets. Summary Recent clinical trial data have enhanced physiology-driven septic shock management and demonstrated improved outcomes. Future studies will aim to further understanding of individual sepsis phenotypes and use of precision therapies.
PURPOSE OF REVIEW:Net ultrafiltration (UFNET) may help correct fluid overload in patients receiving renal replacement therapy (RRT). Yet, how to set it safely at the bedside remains unsettled. This review addresses the hemodynamic aspects of UFNET setting, its time-dependent adjustments in relation phase-dependent balance target, and the contribution of fluid inputs to fluid balance control. RECENT FINDINGS:Hemodynamic instability associated with RRT, the principal obstacle to active fluid removal, arises from vasomotor and cardiac mechanisms, which may or may not be related to UFNET. Fluid balance management, including UFNET setting, evolves across the resuscitation, optimization, stabilization and evacuation phases of care. The U-shaped association between UFNET and mortality is observational and should not be interpreted as a validated bedside target, while fixed prescriptions may prove difficult to deliver. Cardiac output monitoring, preload-dependence assessment and perfusion indices may help predict hemodynamic instability, although comparative evidence that these strategies improve outcomes is lacking. Finally, fluid overload is generated predominantly by nonresuscitation fluids, so that UFNET rate intensity is principally determined by the cumulative volume administered. SUMMARY:Setting UFNET safely requires its titration using repeatedly reassessed hemodynamic tolerance, awareness to phase-dependent fluid balance targets and reduction of fluid inputs.
PURPOSE OF REVIEW:Many antimicrobials used in critically ill patients are predominantly eliminated by the kidneys. Optimizing dosing in this population is challenging as renal clearance is often altered by changes in organ function and presence of extracorporeal circuits. Extrapolating dosing recommendations derived from noncritically ill populations to these patients may not adequately account for these pharmacokinetic changes, increasing the risk of subtherapeutic or toxic drug exposures. This review summarizes contemporary strategies for optimizing antimicrobial dosing in critically ill patients, with a focus on renal dysfunction. RECENT FINDINGS:In resource-limited settings, dosing nomograms developed from critically ill populations provide a practical and effective approach to improving antimicrobial target attainment. Therapeutic drug monitoring is increasingly recommended for a wider range of antimicrobials and can identify patients who require dose optimization. Model-informed precision dosing software has shown promise in improving antimicrobial exposures, although data supporting its impact on clinical outcomes are lacking. Emerging technologies for optimizing antimicrobial dosing include dosing software with artificial-intelligence and real-time monitoring of antimicrobial concentrations with biosensors. SUMMARY:Alterations in renal clearance are a major contributor to suboptimal antimicrobial exposure in critical illness. Selection of dose optimization strategies should be guided by local resources and expertise (see Graphical Abstract).
PURPOSE OF REVIEW:The purpose of this review is to discuss the consequences of severe metabolic acidosis on organ function, examine the physiological controversies surrounding pH correction with sodium bicarbonate, and review the results of recent randomized clinical trials evaluating the effects of sodium bicarbonate on patient-centered outcomes in patients with metabolic acidosis. RECENT FINDINGS:Recent evidence has primarily focused on the results of large multicenter randomized clinical trials, which have shown that sodium bicarbonate administration does not improve mortality in unselected patients with moderate to severe metabolic acidosis, with or without acute kidney injury. However, sodium bicarbonate may delay or reduce the need for kidney replacement therapy in some patients. SUMMARY:Severe metabolic acidosis is associated with organ dysfunction, and its correction with sodium bicarbonate, alongside treatment of the underlying cause, can be performed safely. Although a mortality benefit remains unlikely based on current evidence, sodium bicarbonate administration may be associated with a reduced need for kidney replacement therapy. Future studies aimed at identifying patient phenotypes that may benefit from this intervention are warranted.
Purpose of review To summarize latest evidence on the use of critical care echocardiography for haemodynamic management of the critically ill patient. Recent findings Echocardiography is now considered a cornerstone for hemodynamic management and is recommended by recent guidelines. Its ability to quickly assess undifferentiated shock helps clinicians in diagnosis and immediate management. In stabilizing and optimizing treatment of the shocked patient, serial echocardiography guides fluid, vasopressor, and inotrope therapy while allowing detailed assessment of cardiac structure and function. Echocardiography may be used to assess fluid-responsiveness and myocardial function, conversely, echocardiography and ultrasonography can identify patients who are at risk of harm induced by fluid overload, mechanical ventilation and inotropes, allowing further refinement of therapeutic strategies. When continuous cardiac output monitoring or advanced haemodynamic data are required, echocardiography should be complemented with continuous haemodynamic monitoring rather than used alone. Summary We provide a framework for the optimal use of critical care echocardiography, from a point-of-care tool to a sophisticated hemodynamic monitor.
Purpose of review Albumin preparations are the most common colloids used in critically ill patients worldwide. This review is to provide the physiological rationale and evidence for benefits and harms in different clinical settings. Recent findings There is a strong physiological rationale for intravenous albumin administration in critically ill patients. Iso-oncotic and hyperoncotic albumin have both been used for volume resuscitation and to maintain effective plasma volume at an optimal fluid balance. This practice, however, has not proven to be superior to using crystalloids or balanced solutions with no significant reduction in kidney injury or time on vasopressors. In patients with septic shock and hypoalbuminaemia, albeit limitations, subgroup analysis of a randomized trial suggested reduced mortality with albumin supplementation. Similarly, guidelines strongly recommend the use of albumin in hepatic-induced kidney injury and hepatorenal syndrome. Albumin also improved diuresis when combined with diuretics and may improve intradialytic hypotension. Conversely, hyperoncotic albumin infusion increased the risk of kidney injury and red cell transfusion in high-risk cardiac surgery. Summary Hyperoncotic, and albumin administration in general, is a double-edged sword, its use should be tailored to specific clinical scenarios. The use of hyperoncotic albumin in high-risk cardiac surgery should be discouraged.
Purpose of review To review how ICU illness severity scoring systems perform across settings and over time, and when recalibration is sufficient versus when new models are needed. findings Illness severity scoring systems may consist of a numerical ‘score’ and/or an equation that translates that score or its components into the risk of an outcome such as mortality. The need for periodic updating of a scoring system depends on its primary purpose and on how its performance (discrimination, calibration and validity) varies over time and in different settings. Calibration is most vulnerable to temporal drift, case-mix change and health-system differences, making periodic recalibration essential for benchmarking. Descriptive scores are more stable and often retain good discrimination. They usually need redevelopment only when the relative importance of contributing variables changes or they no longer reflect contemporary practice. Examples including APACHE, ANZROD, SOFA-2, ICNARC, GOSSIS and machine-learning models show recalibration works when predictors remain relevant, whereas rebuilding is preferable when practice, data or modelling methods change substantially. Summary Regular recalibration with periodic rebuilding is generally required for most ICU illness severity scores and prediction models. This should be tailored to the scoring system and the context in which it is used.
Purpose of review The pathogenesis of critical illness drives a dynamic cascade of clinical, metabolic, and immunologic abnormalities through the course of disease. Recent randomized trials show that early full-dose feeding for critically ill patients is ineffective and potentially harmful compared to trophic feeding. The aim of this review is to propose a response-contingent phase-specific strategy of nutrition therapy appropriate for this patient population. Recent findings Barriers to delivering effective nutritional therapy exist, ranging from bioenergetic failure related to mitochondrial dysfunction and gastrointestinal dysmotility with feeding intolerance, to microbial dysbiosis and impaired substrate utilization characterized by inefficient energy production and futile substrate cycling. Emerging concepts are helping to design more appropriate regimens, including estimation of potential benefit from nutritional therapy based on disease severity, risk of net harm, and determination of the stage of enteral nutrition responsiveness, which can be conceptualized as the capacity for achieving phase-specific goals within the constraints of physiologic state, metabolic capacity, safety, and feasibility. Summary Calibrating goals, dosage, monitoring strategies, and expectations from nutritional therapy is required to overcome barriers imposed by the underlying pathophysiology and to optimize support, as these complex patients transition through the acute phase of critical illness towards recovery and rehabilitation.
Purpose of review Invasive mold infections (IMIs) remain a major cause of morbidity and mortality in patients with hematological malignancies, particularly when critical illness develops. Advances in hematological therapies and intensive care medicine have increased the number of high-risk patients admitted to intensive care units (ICUs), where invasive aspergillosis and other mold infections represent important causes of acute respiratory failure and sepsis. This review summarizes current knowledge on IMIs in critically ill hematological patients, focusing on epidemiology, diagnosis, and management. Recent findings The epidemiology of IMIs is evolving, with increasing recognition of non-Aspergillus molds, including Mucorales , Fusarium , Scedosporium , and Lomentospora species. Diagnosis in the ICU remains challenging because clinical and radiological findings are often nonspecific and conventional diagnostic criteria may be difficult to apply. Recent advances in imaging, fungal biomarkers, and molecular techniques have improved early detection, while new antifungal agents are expanding therapeutic options. Summary IMIs continue to be associated with high mortality in critically ill patients with hematological malignancies. Early diagnosis, prompt initiation of appropriate antifungal therapy, and multidisciplinary management are essential to improve outcomes. Future efforts should focus on ICU-specific diagnostic strategies, risk stratification, and the integration of emerging antifungal therapies.
Purpose of review Survivorship of critical illness has increased, shifting attention toward recovery and long-term outcomes. Post-ICU nutrition is emerging as a clinically relevant, yet underperforming contributor to functional recovery and quality of life. Persistent nutritional inadequacy reflects insufficiently defined physiological requirements and limited implementable evidence-based guidance during ICU recovery. Recent findings Energy and protein delivery sharply decline after ICU discharge, despite persistent metabolic demands. Underfeeding can result from the absence of recovery-specific targets, patient-level barriers (e.g. appetite loss, dysphagia, fatigue), and fragmented care transitions, including premature feeding-tube removal and suboptimal monitoring of oral intake. Structured patient and family engagement can help operationalize individualized nutritional strategies and improve feasibility without substantial resource burden, acting as continuity agents. Summary Post-ICU nutritional failure reflects combined physiological and implementation challenges. Clinicians should recognize the post-ICU hospitalization period as a potential ‘metabolic danger zone’, requiring a shift from acute-phase restrictive feeding toward strategies prioritizing functional recovery and lean mass preservation. Improving outcomes requires standardized, yet adaptable, care pathways that bridge ICU-to-ward transitions, operationalize individualization, and integrate patient and family input as clinical instruments. Future research should prioritize multicenter implementation studies centered on ‘disability-free survival’ to inform adaptive, evidence-based nutritional protocols.
Purpose of review Clinical models are commonly applied in critical care for both descriptive and predictive purposes. However, methodological rigour is often lacking in their development and validation. This review examines the principles underlying the multiple domains of model validity. We argue that a clear model purpose and theoretical framework are essential preconditions for validity. Recent findings Recently developed descriptive and predictive models illustrate different approaches to promoting validity. In developing SOFA-2, eCARTv5, Sepsis-3 and the PHOENIX paediatric sepsis criteria, authors used combinations of expert-driven consensus, data-driven derivation and iterative refinement. These examples demonstrate that validity requires a process of repeated evaluation across distinct populations, settings and time periods. Summary The best approach to establishing validity combines a clear theoretical framework, structured expert consensus (including Delphi methodology), rigorous statistical evaluation (discrimination, calibration, net benefit) and prospective external validation. The distinction between models designed to predict outcomes and those designed to describe or quantify organ dysfunction is fundamental and should guide development and validation strategy from the outset.
PURPOSE OF REVIEW:This review aims to provide a summary of recent updates in resuscitation and vasopressor strategies for septic shock, as well as advancements in precision therapy. RECENT FINDINGS:Septic shock results from a dysregulated host response to infection and remains a significant cause of global morbidity and mortality. While standard care of septic shock remains protocolized due to improved outcomes with timely antibiotic and fluid administration, recent data have informed a more nuanced, individualized approach to sepsis management. Increasing evidence suggests that septic shock results from dynamic phases of immune dysregulation that may provide targets for precision therapy and data from large clinical trials have informed a complementary approach to fluid and vasopressor administration, rather than a fixed, fluid-centric approach. Results additionally suggest improved outcomes with integration of multimodal perfusion targets, as well as an individualized approach to invasive hemodynamic monitoring and endpoints of resuscitation, such as capillary refill time and mean arterial perfusion pressure targets. SUMMARY:Recent clinical trial data have enhanced physiology-driven septic shock management and demonstrated improved outcomes. Future studies will aim to further understanding of individual sepsis phenotypes and use of precision therapies.
PURPOSE OF REVIEW:We highlight publications from the year 2025 that examined the contribution of age, frailty, and chronic conditions to outcomes in ICU patients aged 80 years and older. Traditional prediction models are less precise in this population, partly due to the limited inclusion of very old patients in risk prediction tools such as SAPS and APACHE, as well as the absence of geriatric-specific variables in these models. RECENT FINDINGS:Beyond chronological age, the most important variables associated with survival in this group are general health factors, including frailty and the presence of chronic diseases (multimorbidity). This review discusses studies published over the past year that focus on the impact of these conditions in ICU patients aged over 80 years. There is also a growing focus on nonagenarians, with emerging evidence supporting ICU admission in selected patients within this age group. An important subgroup comprises patients with cognitive impairment. While cognitive outcomes are well described in ICU survivors, less is known about the impact of pre-ICU cognitive decline on outcome. SUMMARY:Findings from these studies confirm increased mortality in this population. However, greater emphasis should be placed on functional outcomes, as well as on the "second victims"-family members and caregivers.
Purpose of review This manuscript provides an overview of common and uncommon central nervous system (CNS) infections seen in intensive care settings. Recent findings Epidemiological studies have demonstrated longitudinal changes in community-acquired bacterial meningitis. Large cohorts have better informed current understanding of both brain abscess and ventriculitis. International trials have led to advancement in the treatment of cryptococcal and tuberculosis meningitis, which is continuing to be studied and optimized for specific patient sub-populations. Recent retrospective data has further defined the spectrum of viral encephalitis and the nuances of diagnostic evaluation. Summary Neuro-infectious disease in critically ill patients presents challenges of both timely accurate diagnosis and availability of effective treatments. Vaccination-associated shifts in epidemiology coupled with enhanced identification of infectious organisms and recent international clinical trials will continue to evolve existing treatment algorithms. CNS infections in immunocompromised patient populations remain to be an active area of study.
Purpose of review Severe community-acquired pneumonia (sCAP) remains one of the most lethal infectious syndromes in critical care, with mortality remaining persistently high despite decades of antimicrobial and supportive care advances. This review appraises recent developments in diagnostics, microbiology, and host-response biology, and advocates for a fundamental shift toward precision-driven management. Recent findings High-resolution molecular diagnostics have exposed the true complexity of sCAP, revealing a substantial viral burden and a polymicrobial ecosystem that challenges traditional pathogen-centric models. Yet, this diagnostic revolution has failed to translate into meaningful antimicrobial stewardship, reflecting a persistent disconnect between detection and decision-making. At the same time, multiomic and transcriptomic studies have redefined sCAP as a biologically heterogeneous syndrome, characterized by divergent host-response states ranging from hyperinflammation to immune dysfunction. These insights are beginning to reshape therapy, supporting phenotype-directed immunomodulation, including selective corticosteroid use and biomarker-guided interventions such as interleukin-1 blockade. In parallel, artificial intelligence and radiomics are emerging as powerful tools capable of integrating complex, multidimensional data, although their clinical utility remains largely unrealized. Summary sCAP should no longer be approached as a uniform infectious disease but as a spectrum of biologically distinct endotypes. The future lies in integrating pathogen detection with real-time host profiling and advanced analytics to enable truly personalized care. Without this paradigm shift, further gains in outcomes are unlikely.
PURPOSE OF REVIEW:National ICU benchmarking systems are critical infrastructure for evaluating and improving the quality of critical care across all settings. This review summarizes the recent literature on establishing, operating, and sustaining such systems, drawing on evidence from registries across high-income countries (HICs) and low-and-middle-income countries (LMICs). RECENT FINDINGS:Recent evidence not only confirms the continued expansion of national ICU registries globally but also reveals persistent heterogeneity in data architecture and severity adjustment approaches. Key advances include the development of common data models enabling international collaboration (LOGIC consortium), the use of federated analysis for score development (SOFA-2), and the validation of simplified severity scores for resource-limited settings. Calibration drift remains universal, requiring periodic reassessment of risk-adjustment models. New methodological work highlights the impact of atypical patients and potential organ donor admissions on standardized mortality ratios. While 46% of registries support observational research, only 22% currently enable interventional studies - representing a major opportunity for the field. SUMMARY:Establishing a national benchmarking system requires deliberate choices about data architecture, severity adjustment, governance, and feedback mechanisms. Challenges vary across the registry lifecycle, from securing initial buy-in and ensuring data quality at scale to maintaining engagement and model accuracy at maturity. The ultimate measure of a benchmarking system is not only the volume and coverage of the data but also the improvements in care it enables.
