Acute respiratory distress syndrome (ARDS) is a form of acute lung injury characterized by increased alveolar-capillary permeability and non-cardiogenic pulmonary edema. Mechanical ventilation remains the cornerstone of supportive care, but ventilatory support itself can worsen lung injury. Current guidelines recommend focusing on minimizing ventilator-induced lung injury through volume and pressure limitation (lung-protective ventilation). In selected patients, noninvasive strategies such as high-flow nasal cannula and noninvasive ventilation may prevent intubation. For patients requiring invasive ventilation, lung-protective ventilation (low tidal volume, limitation of plateau and driving pressures, positive end-expiratory pressure titration), prone position, and judicious use of neuromuscular blockade improves outcomes in moderate and severe ARDS. Advanced bedside monitoring tools, including esophageal pressure manometry, electrical impedance tomography, computed tomography, and lung ultrasound, have been proposed in the literature to monitor respiratory mechanics, regional ventilation, and recruitability, enabling clinicians to tailor ventilatory strategies to individual physiology.
Acute kidney injury (AKI) is a common syndrome in critically ill patients, carrying significant implications for morbidity and mortality. The etiology and severity of AKI vary, requiring a management approach that focuses on prevention, treatment of the underlying cause, and supportive care, often involving renal replacement therapy. Numerous strategies have been proposed for preventing and treating AKI. This narrative review aims to provide a concise summary of the clinical management of AKI in critically ill patients tailored to clinicians working in the perioperative setting.
Stress-induced cardiomyopathy (siCM), also known as Takotsubo syndrome, is an acute, transient, and typically reversible form of myocardial dysfunction. In the intensive care unit (ICU), siCM remains underrecognized because its clinical presentation, electrocardiographic abnormalities, and biomarker profile often overlap with acute coronary syndromes and other critical illness-associated cardiomyopathies. Unlike the emotional triggers commonly described in ambulatory populations, ICU-associated siCM is more frequently precipitated by severe physiologic stressors, including sepsis, neurologic injury, respiratory failure, major surgery, and exposure to vasoactive therapies. The pathophysiology of siCM is multifactorial and incompletely understood but appears largely driven by excessive sympathetic activation and catecholamine-mediated myocardial injury. Additional contributory mechanisms include coronary microvascular dysfunction, myocardial metabolic stress, neurocardiac axis dysregulation, and inflammatory signaling. Individual susceptibility factors, including postmenopausal estrogen deficiency and genetic variation in adrenergic pathways, may further increase vulnerability. Early recognition and ICU-specific diagnostic strategies are essential to improve management and outcomes in critically ill patients.
Traditional Extracorporeal Blood Purification (EBP) rationales have focused on a concentration-dependent hypothesis of cytokine removal. However, emerging evidence suggests that a strictly plasma-centric interpretation is insufficient due to multicompartmental solute kinetics. This review proposes a comprehensive mechanistic framework for EBP, integrating mediator-directed and cell-directed immunomodulation. While mediator-directed therapies (e.g., AN69ST, PMMA membranes, and selective sorbents) aim to reduce the circulating burden of PAMPs and DAMPs, cell-directed interventions (e.g., PMX-HA, SCD) focus on "reprogramming" activated or exhausted leukocytes to restore immune homeostasis. The transition toward precision medicine in sepsis requires the integration of theragnostic biomarkers-such as mHLA-DR, NLR, and NETosis markers-to identify specific immune endotypes. Ultimately, EBP must evolve from device-agnostic applications to phenotype-driven approaches that optimize the timing and selection of extracorporeal support to improve clinical outcomes.
With increases in patient acuity, the use of devices that provide Mechanical Circulatory Support (MCS) is increasing rapidly. By extension, anesthesiologists are increasingly called upon to manage patients supported by MCS. The type of MCS can be categorized into left ventricular support, right ventricular support, biventricular support, and whether or not respiratory support (oxygenation and ventilation) is provided. Examples of MCS types include intra-aortic balloon pump (IABP), venoarterial extracorporeal membrane oxygenation (VA ECMO), venovenous ECMO, and transvalvular microaxial flow pumps. Clinical scenarios include patients already supported by MCS devices that require a procedure (such as exploratory laparotomy), patients requiring planned periprocedural support (such as VA ECMO for ventricular tachycardia ablation), and patients that acutely decompensate and require emergent rescue (such as cardiac arrest requiring VA ECMO). This review presents the available literature on select MCS types, anesthetic considerations by MCS type, and future research directions.
Anesthesia for liver transplantation poses myriad challenges due to surgical complexity and the multisystem pathophysiology associated with end-stage liver disease. Cirrhosis-related pathologies such as portopulmonary hypertension and hepatorenal syndrome may further complicate perioperative management, and intraoperative complications such as the development of intracardiac thrombus or post-reperfusion syndrome can cause catastrophic hemodynamic consequences that require advanced management, including mechanical circulatory support. This review summarizes recent advances in liver transplant anesthesia to inform best practices for managing this increasingly complex patient population.
Point-of-Care Ultrasound (POCUS) has become a core competency for the anaesthesiologist managing patients in the postoperative intensive care unit. By providing immediate bedside imaging without consultative delay, it enhances diagnostic accuracy and directly informs haemodynamic and respiratory decision-making. This review addresses five clinical domains: lung and diaphragm assessment, cardiac evaluation and shock classification, fluid management, abdominal screening and deep vein thrombosis assessment, and procedural guidance. For each domain, sonographic findings, clinical interpretation, and management implications are described. A structured multi-organ approach with mandatory re-evaluation after every intervention is emphasised throughout. Governance requirements, including competency assessment, image archiving, and peer review are discussed alongside their medico-legal implications. Diagnostic accuracy is well established across all domains; randomised outcome data remain the principal evidence gap. Artificial intelligence may reduce operator dependency but requires prospective perioperative validation before routine implementation.
Blood component transfusion remains a common intervention in critically ill patients and is primarily used to support oxygen delivery and correct coagulopathy. Over the past two decades, evidence from randomized trials and systematic reviews have supported the adoption of restrictive transfusion strategies in most critically ill populations. However, transfusion decisions should be individualized in patients with conditions involving ischemia-sensitive organs, including acute myocardial infarction and acute neurologic injury, where higher thresholds may be appropriate. Management of bleeding and coagulopathy in critical illness also involves platelet transfusion, coagulation factor replacement, and antifibrinolytic therapy. Increasingly, viscoelastic assays are used to guide targeted hemostatic therapy. Although transfusion can be lifesaving, it carries potential risks including transfusion reactions, circulatory overload, and transfusion-related lung injury. Optimal transfusion practice therefore requires balancing physiologic need with transfusion-related risks while applying evidence-based thresholds within the clinical context of critical illness.
Pain management and sedation for critically ill patients remain areas of active interest and debate among intensivists. We review the foundational literature behind practices now considered the standard of care, including a systematic approach to target light sedation as well as the avoidance of benzodiazepine use. These approaches facilitate earlier liberation from mechanical ventilation, shorten intensive care unit length of stay, and reduce delirium. We also discuss the relative merits of dexmedetomidine versus propofol, analgesia-first sedation protocols, emerging medications and areas for future investigation.
Post-intensive care syndrome (PICS) is a common and multifaceted consequence of critical illness, affecting more than half of ICU survivors and encompassing persistent physical, cognitive and mental health impairments that may last for years and impair quality of life and functional recovery. Physical limitations, including ICU-acquired weakness and reduced exercise capacity, frequently coexist with mental health disorders and cognitive impairment. The burden extends to family members (PICS-F), who commonly experience psychological distress and reduced well-being. Risk factors include premorbid vulnerability as well as ICU-related exposures and complications. Preventive strategies focus on optimizing ICU care, particularly through the ABCDEF bundle (Assess, prevent and manage pain; Both spontaneous awakening and breathing trials; Choice of analgesia and sedation; Delirium assessment, prevention and management; Early mobility and exercise; and Family engagement and empowerment), while structured follow-up with early, targeted screening in high-risk patients is recommended to identify impairments and guide management across the recovery continuum.
Airway point-of-care ultrasound (POCUS) has the potential to make airway assessment and planning more accurate and complete. Studies have examined feasibility and usefulness of POCUS to predict and facilitate difficult airway management. This paper presents a brief overview of contemporary POCUS airway applications and current opinion on their place in clinical practice. Despite evidence, infraglottic airway assessment and its potential to improve patient safety remains relatively underused. A case series is presented to illustrate the translation of POCUS training to real life routine and acute practice. For each case, how ultrasound contributed to decision-making, preparedness, and successful management of challenging airways is highlighted. Understanding the airway’s true orientation and midline through imaging helps prevent failed front-of-neck access (FONA) attempts and supports deliberate, safe airway strategies. Wider adoption, structured training, and further research are needed to standardize POCUS airway techniques and evaluate their impact on patient outcomes.
Point-of-care ultrasound (POCUS) has transformed pediatric acute care by enabling rapid, bedside assessment that enhances diagnostic precision and procedural safety across perioperative, emergency, and critical care settings. Core pediatric POCUS applications include lung, cardiac, gastric, abdominal, vascular, and airway imaging. Lung and cardiac ultrasound improve evaluation of ventilation, effusions, and hemodynamic function, while gastric ultrasound assists in aspiration risk assessment. Abdominal and vascular applications enhance trauma evaluation and procedural success, and airway ultrasound aids in tube placement and emergency access. As POCUS becomes a core clinical competency, contemporary trainees are gaining formal proficiency, and established clinicians are integrating it into practice. Broader adoption, standardized education, and ongoing research are essential to optimize its role in improving pediatric patient outcomes.
Point-of-care ultrasound (POCUS) has greatly transformed bedside patient care by enabling clinicians to conduct rapid, non-invasive evaluations of cardiac structure and function. This review presents a systematic approach to structural and functional cardiac assessment using POCUS, with an emphasis on left and right ventricular dimensions and function, preload and volume responsiveness, and valvular assessment. The echocardiographic measurements that can be readily performed at the bedside are discussed. This review also emphasizes the vital role of POCUS in identifying life-threatening conditions, such as pericardial effusion and tamponade, acute pulmonary embolism, cardiogenic shock due to left ventricular failure, hypovolemic shock, and aortic stenosis. Finally, the importance of clinician training in cardiac POCUS is highlighted, with a focus on standardized methods, structured training programs, and developing clinician competencies.
Cardiac surgery poses several unique challenges for perioperative physicians and surgeons, and thorough preoperative assessment and investigation are imperative. Meticulous preoperative assessment and investigations allow selection of appropriate surgical procedures, identification of patients at high risk of perioperative complications, and crafting individualized perioperative care plans for these patients. Our review describes many facets of pre-operative investigations for patients undergoing cardiac surgery, highlighting their importance and limitations.
Background Cardiac surgery presents significant perioperative risks, particularly for high-risk populations such as elderly and frail patients. Prehabilitation, a preoperative strategy focusing on patient optimization, has emerged as a promising intervention to enhance recovery and reduce complications. Objectives This review explores the evidence supporting prehabilitation programs, which integrate exercise, nutritional optimization, psychological support, and patient education to improve cardiac surgical outcomes. Methods A review of current literature highlights the benefits, challenges, and emerging multidisciplinary approaches in cardiac prehabilitation, including inspiratory muscle training and tailored nutritional support. Results While prehabilitation is well-established in other surgical specialties, its implementation in cardiac surgery remains limited due to protocol heterogeneity, time constraints, and patient-specific factors. Early data suggest improved recovery, reduced hospital stays, and better perioperative outcomes. Conclusions Standardized prehabilitation protocols and additional research are necessary to improve patient selection, increase adherence, and assess long-term effects. With around one million cardiac surgeries conducted worldwide annually, incorporating structured prehabilitation programs may enhance patient outcomes and refine perioperative care.
Cardiac surgery carries substantial risks, particularly for an aging population with increased frailty, morbidity, and malnutrition. Prehabilitation and Enhanced Recovery After Surgery (ERAS) protocols are emerging as essential strategies to optimize patients before surgery and accelerate postoperative recovery. In this review, we explore the role of prehabilitation and ERAS protocols in cardiac surgery, identify the challenges in implementing these strategies, and highlight areas for future research. Prehabilitation involves structured interventions such as physical conditioning, respiratory training, nutritional optimization, psychological support, and lifestyle modifications. While prehabilitation's role in non-cardiac surgery is well-established, its application in cardiac surgery remains less defined due to a lack of high-quality trial data and variability in studies. ERAS protocols, initially designed for colorectal surgery, have been adapted for cardiac surgery to include patient education, early mobilization, multimodal analgesia, and blood conservation techniques. Despite promising evidence regarding prehabilitation and ERAS protocols, the widespread adoption in cardiac surgery has been hindered by patient heterogeneity, limited access, and logistical constraints. The potential benefits include reduced complications, shorter hospital stays, improved recovery, and better patient outcomes. Future research should focus on standardizing prehabilitation protocols, assessing their impact on high-risk populations, and exploring telemedicine solutions to enhance accessibility.
Optimization of pulmonary health and risk mitigation is a critical component of preoperative preparation for cardiac surgery, impacting both short- and long-term postoperative outcomes. A wide array of tests and interventions have been studied such as pulmonary function testing, pulmonary risk stratification, and prehabilitation therapies. While each intervention has its utility, there lacks consensus on pulmonary evaluation and optimization prior to cardiac surgery. Special consideration should be given to the preoperative management and treatment of underlying comorbid pulmonary conditions that frequently impact postoperative outcomes. Targeted approaches have demonstrated potential to mitigate the risks associated with these conditions and improve surgical outcomes. This review aims to summarize recommended preoperative pulmonary evaluation and prehabilitation protocols, and discuss targeted approaches for patient-specific comorbidities to optimize patients and reduce postoperative complications in cardiac surgery.
