Purpose of review Cardiac arrest carries high mortality and morbidity, driven in part by a profound mixed respiratory and metabolic acidosis arising from hypoperfusion during cardiopulmonary resuscitation and ischemia-reperfusion injury after return of spontaneous circulation (ROSC). Severe acidosis impairs cardiovascular function, oxygen delivery, CO 2 transport, and cellular metabolism, potentially worsening outcomes. This review examines the physiological rationale and current evidence for pH-targeted therapies in cardiac arrest. Recent findings Sodium bicarbonate remains the most studied buffer, but randomized trials and observational studies have largely failed to demonstrate improved survival or neurological outcomes. Its efficacy depends critically on adequate ventilation to eliminate generated CO 2 , a frequently overlooked variable. Sodium lactate has emerged as a promising alternative, offering buffering capacity alongside utility as an oxidizable energy substrate, with encouraging experimental data, though clinical evidence remains preliminary. Key gaps persist regarding optimal timing, dosing, and the interaction between buffer administration and ventilatory strategy. Summary Despite limited support for routine bicarbonate use, pH-targeted interventions retain strong physiological plausibility, and remains a promising field for future research.
Purpose of review Traumatic hemorrhagic shock remains the leading preventable cause of early trauma death, with most deaths occurring within the first 24 h. This review summarizes recent advances in prediction tools, transfusion protocols, blood products and monitoring strategies for transfusion management. Recent findings Transfusion management relies on early activation of major hemorrhage protocols and rapid delivery of balanced blood components to limit coagulopathy and restore oxygen delivery. Prehospital transfusion appears most beneficial in the most severely injured patients, particularly with prolonged transport times, though its mortality benefit varies across trauma systems and patient phenotypes. Low-titer group O whole blood simplifies logistics and may improve early hemostasis, but randomized trials have not shown a clear survival advantage over component therapy. Viscoelastic testing complements empirical algorithms by enabling faster, targeted correction of fibrinogen and factor deficiency. Emerging data also highlight the prognostic impact of ionized calcium disturbances and the potential of machine-learning models for early risk stratification. Summary Current evidence supports a time-critical, system-based approach in which standardized transfusion bundles are triggered early and refined using viscoelastic guidance. Future work should prioritize prospective validation of decision-support tools, phenotype-specific strategies, clarification of whole blood's role, and rigorous evaluation of emerging blood products.
Purpose of review Acute kidney injury (AKI) affects more than half of critically ill patients, and 10–15% require acute renal replacement therapy (RRT). Despite comparable outcomes among appropriately delivered RRT modalities, substantial practice variation persists due to differences in organizational structures, resources availability, and implementation of evidence-bases care. This review summarizes recent advances in quality improvement for acute RRT, including quality frameworks, key performance indicators (KPIs), and implementation science. Recent findings The Acute Disease Quality Initiative (ADQI) established a framework for evaluating acute RRT quality across structure, process, and outcome domains and developed consensus-based KPIs for continuous RRT (CRRT). Key CRRT quality measures include program leadership, education and training, filter life, treatment downtime, access alarms, dose-intensity, ultrafiltration, adverse events, RRT discontinuation, and ICU mortality. Institutional QI initiatives demonstrate that multidisciplinary collaboration, standardized protocols, electronic medical record integration, and continuous audit and feedback can improve treatment delivery, adherence to evidence-based practices, and resource utilization. Contemporary registries are generating data to validate KPIs, characterize practice variation, and establish performance benchmarks. Summary Quality improvement is essential for optimizing acute RRT delivery. Integrating standardized quality measurement with implementation science provides a practical framework to reduce practice variation, improve RRT delivery, and enhance patient outcomes.
Purpose of review The resuscitation room is among the most complex clinical environments in modern medicine, and a substantial proportion of preventable mortality stems from organizational, communicational, and decision-making failures rather than individual technical deficits. This review summarizes recent evidence across individual cognition, collective team intelligence, structured learning, and technological decision support to outline an integrated framework for optimizing resuscitation-room performance. Recent findings Cognitive overload, interruptions, and biases such as anchoring and premature closure consistently impair individual decision-making under pressure, while adaptive expertise and structured cognitive aids help offload working memory. At the team level, collective intelligence, shared mental models, closed-loop communication, and psychological safety increasingly outperform individual expertise as determinants of safety, though most supporting evidence remains simulation-based or process-based. Structured debriefing and trauma video review support systematic learning, with each T-NOTECHS point associated with roughly 11% fewer adverse events, yet debriefing timing shows no clear survival benefit. Technological decision-support tools show consistent gains in process measures (guideline adherence, cognitive load, time-based metrics), but high-quality evidence of patient-centred outcome improvement remains scarce, and voice-recognition or augmented (AR)/virtual reality (VR) integration remains preliminary and unvalidated operationally. Summary Optimizing resuscitation-room performance requires an integrated systems-based approach combining individual cognitive support, deliberate team design, structured collective learning, and cautiously implemented technology, while unresolved questions around deskilling, cognitive burden, and system resilience warrant further prospective, outcome-focused research.
