Sepsis is a life-threatening medical emergency in which prompt initiation of targeted antimicrobial therapy is crucial for patient survival. Historically, clinicians have relied on empirical broad-spectrum antibiotics owing to the 48-to-72-hour turnaround time of conventional blood cultures, while traditional host-response biomarkers offer limited pathogen-specific utility. This review highlights the recent paradigm shift in the microbiological diagnostics for sepsis, which is transitioning from conventional methods to rapid diagnostic tests (RDTs). Pre-analytic considerations for blood culture are of paramount importance as the foundation for all downstream RDT applications. We explore the clinical integration of matrix-assisted laser desorption/ionization time-of-flight mass spectrometry and highly multiplexed genotypic assays, which provide rapid species identification and limited profiles of genotypic resistance directly from positive blood cultures. The critical need for rapid phenotypic antimicrobial susceptibility testing is addressed, alongside the emerging technologies for culture-independent microbial detection. Crucially, technological advancement alone is insufficient: the true clinical benefits of RDTs would be achieved only when RDTs are coupled with robust diagnostic and antimicrobial stewardship programs. In the context of globally escalating antimicrobial resistance, and with a specific focus on the high prevalence of multidrug-resistant organisms in South Korea, the seamless integration of these advanced diagnostic systems into multidisciplinary clinical workflows underscores the urgency and opportunities of this paradigm shift.
Background: Transporting critically ill trauma patients for fluoroscopy-guided peripherally inserted central catheter (PICC) placement poses substantial risks. This study evaluated the clinical outcomes of bedside PICC insertion using a surface anatomical landmark-based measurement in a trauma intensive care unit (ICU).Methods: This retrospective cohort study included trauma ICU patients who underwent PICC insertion between September 2023 and August 2024 at a regional trauma center. Insertion location was categorized as bedside or fluoroscopy-guided. Outcomes included optimal tip positioning, aberrant-course malposition, complication rates, and catheter dwell time. Multivariable linear regression identified factors associated with PICC duration.Results: Among 282 PICC procedures (171 bedside, 111 fluoroscopy), the bedside group had significantly higher injury severity scores and more frequent mechanical ventilation. Using the cm-based carina-distance criterion, optimal tip positioning was achieved in 73.1% of bedside and 65.5% of evaluable fluoroscopy-guided insertions (P=0.184). However, using the vertebral body unit-based radiologic criterion, target-zone achievement was lower in the bedside group than in the fluoroscopy group (48.5% vs. 64.9%). Initial aberrant-course malposition occurred in nine bedside insertions (5.3%) and in no fluoroscopy-guided insertions, and all were corrected before clinical use. Overall complication rates were comparable (17.5% vs. 18.0%, P=0.919). Conclusions: Bedside PICC insertion using a surface anatomical measurement method may be a feasible transport-free option for selected critically ill trauma ICU patients.
Background: Data on the long-term nutritional status of pediatric intensive care unit (PICU) survivors are limited, and the association with functional outcomes is unknown. The primary objectives were to determine the prevalence of post-intensive care malnutrition and its relationship with functional outcomes at 1 month and 1 year after PICU discharge. Methods: A retrospective chart review of all children aged 1 month to 15 years who were admitted to the PICU for >48 hours from July 2019 to January 2024 and had visits to the pediatric post-intensive care clinic at 1 month and 1 year after hospital discharge was conducted. Malnutrition was categorized using the body mass index according to the World Health Organization Growth Reference. Functional outcome was classified using the Pediatric Cerebral Performance Category. Results: A total of 129 children were included in the final analysis. Malnutrition was observed in 46 children (35.6%) at 1 month after discharge and in 29 children (22.5%) at 1 year after discharge. Children with baseline malnutrition were associated with malnutrition at both follow-up time points. Longer ventilator days were observed among children with malnutrition at both time points, and children who had malnutrition at 1 year had longer PICU stays. At least moderate dysfunction was associated with any malnutrition and wasting at 1 year after discharge, but not with overweight. Conclusions: Malnutrition was found in a substantial proportion of PICU survivors, with an association with poor long-term PCPC-related functional outcomes. Long-term nutritional follow-up and support should be warranted to optimize outcomes.
Background: Central venous catheterization (CVC) is an essential procedure in the management of critically ill pediatric patients. However, the optimal catheter insertion site remains controversial due to varying complication rates. This study aimed to evaluate the feasibility and safety of subclavian vein (SCV) catheterization compared to femoral vein (FV) and internal jugular vein (IJV) access in a pediatric intensive care setting.Methods: This retrospective study included all patients admitted to the pediatric intensive care unit (PICU) of a tertiary hospital over a one-year period (March 2022–March 2023) who underwent nontunneled central venous catheter placement.Results: Among 174 patients included (median age 29 months, 60.3% male), 52.9% had SCV, 23.6% FV, and 23.6% IJV catheterization. The overall CVC success rate was 99.4%. There was no statistically significant difference in mechanical complications, catheter-related bloodstream infections, or thrombosis between groups, however, thrombosis occurred most frequently in the FV group (12.2%). The median age in the SCV group was significantly lower than in the other groups (20 months; interquartile range, 10–63; P<0.001), while the presence of chronic diseases was significantly higher in this group (P=0.02). In multivariate logistic regression, catheter site was identified as the only independent predictor of thrombosis, with FV catheterization associated with increased risk (OR, 2.75; P=0.016).Conclusions: SCV catheterization appears to be a feasible and safe option for critically ill children, even in younger patients and in the presence of chronic comorbidities. Despite potential technical challenges, SCV access represents a viable alternative to IJV and may offer potential advantages over FV, particularly with regard to thrombosis risk.
Background: Early rehabilitation is important in critical care, but nationwide data on rehabilitation practices in Korean intensive care units (ICUs) are lacking. This study reports the findings of a 1-day point-prevalence survey to assess current ICU rehabilitation practices and associated ICU characteristics.Methods: A nationwide, 1-day point-prevalence survey was conducted on December 18, 2024, across 116 ICUs with a 24-hour follow-up. Data were collected at the ICU level and included ICU characteristics, staffing and equipment, the total number of admitted patients, the number of patients receiving rehabilitation, types and frequency of interventions, and reasons for non-provision.Results: Complete data were obtained for 1,529 patients from 116 ICUs. Among them, 374 patients (24.5%) received at least one rehabilitation intervention on the survey day. A total of 968 recorded rehabilitation interventions were delivered, of which 70.5% were physical and 23.1% respiratory rehabilitation. Most physical rehabilitation consisted of in-bed activities, while out-of-bed mobilization accounted for only 7.3% of all recorded rehabilitation interventions. Both the overall rehabilitation rate and out-of-bed mobilization were significantly higher in ICUs within larger hospitals and those with dedicated rehabilitation personnel. Conclusion: Rehabilitation was delivered to 24.5% of ICU patients present on the survey day, with out-of-bed mobilization representing a small proportion of recorded rehabilitation interventions. These findings describe rehabilitation delivery at the population level of surveyed ICU inpatients rather than uptake among medically eligible patients. Broader implementation of ICU rehabilitation may require institutional and systemic support, including dedicated rehabilitation personnel, reduced ICU workload burden, and consideration of appropriate reimbursement structures.
Background: Hematologic markers derived from complete blood counts have emerged as potential cost-effective prognostic indicators. Sepsis-induced left ventricular diastolic dysfunction (LVDD) is associated with increased mortality rates. We evaluated the predictive value of serially measured hematologic markers for 30-day mortality and their relationship with LVDD in patients with septic shock.Methods: This retrospective cohort study analyzed adult patients diagnosed with septic shock in the emergency department of a university hospital between March 2014 and May 2018. Serial neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio, and lymphocyte-to-monocyte ratio (LMR) values were recorded from admission to day 5. The relationship between hematologic markers and LVDD was evaluated in patients who underwent transthoracic echocardiography (TTE).Results: In total, 431 patients were included, with a 30-day mortality rate of 12.5%. The NLR on day 5 and NLR day 5/day 1 ratio had the highest predictive performance (area under the receiver operating characteristic curve [AUROC], 0.743 and 0.746, respectively). Similarly, the LMR on day 5 and the LMR day 5/day 1 ratio showed strong prognostic value (AUROC, 0.707 and 0.753, respectively). In the subgroup analysis of 204 patients who underwent TTE, a higher NLR at admission was significantly associated with LVDD (odds ratio, 1.016; 95% CI, 1.000–1.031; P=0.043).Conclusions: Serial measurements of the NLR and LMR showed better predictive value for 30-day mortality in patients with septic shock than measurements from a single time-point. These findings support the use of hematologic markers as adjunctive tools for risk stratification of patients with septic shock.
Patient–ventilator asynchronies (PVA) are associated with adverse clinical outcomes, including prolonged ventilatory support and increased mortality both in the intensive care unit (ICU) and at the hospital level. Despite their clinical relevance, the detection and management of PVA remain challenging in daily practice because of multiple factors, such as the lack of continuous monitoring and the low recognition by healthcare professionals. The aim of this review is to map and synthesize the available evidence on the main challenges in the identification and management of PVA and to describe the strategies proposed to overcome them. We conducted a scoping review following Joanna Briggs Institute guidance and reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR). PubMed/Medline, Scopus, ScienceDirect, LILACS, and the Cochrane Library were searched from inception to April 2025. Two reviewers independently screened records and selected eligible studies. Data were charted using a standardized extraction form, and findings were synthesized descriptively. The identified challenges were categorized into three main groups, and the proposed strategies were classified according to the type of challenge addressed. The scoping review included 33 studies published between 2000 and 2025. Of these, 17 provided explanatory evidence, whereas 16 described strategies for addressing challenges in daily clinical practice. Overall, this scoping review identified 15 distinct challenges. This review highlights the multifaceted challenges affecting the recognition and management of PVA in adult ICU patients. By mapping challenges across clinical, structural, and cultural domains and summarizing strategies to address them, this review provides professionals with a practical framework to improve patient–ventilator interaction.
Background: Hypertonic saline (HTS) is used for hyperosmolar therapy in acute ischemic stroke (AIS) but is traditionally administered via central venous catheter to minimize vascular complications. Procedural burden and urgency often necessitate peripheral administration in practice. We investigated phlebitis risk associated with peripheral 11.7% HTS in AIS patients requiring hyperosmolar therapy.Methods: This retrospective study included 200 AIS patients receiving hyperosmolar therapy with mannitol (January 2022–December 2024), classified into an HTS group (n=67) receiving additional peripheral 11.7% NaCl and a no-HTS group (n=133). Phlebitis was assessed using the Infusion Nurses Society Phlebitis Scale. The primary outcome was phlebitis within 72 hours of therapy initiation. Multivariable logistic regression assessed the independent association between HTS use and phlebitis, with a secondary analysis examining frequency-dependent risk.Results: Phlebitis occurred in 31.3% (21/67) of the HTS group versus 15.8% (21/133) of the no-HTS group (P=0.016). Among those with phlebitis, most cases were mild (grade 1, 90.5%; grade 2, 9.5%), with no grade 3 or higher events. HTS was independently associated with phlebitis (adjusted OR, 2.19; 95% CI, 1.02–4.70; P=0.044) but not with mortality or hospital length of stay. Single administration was not associated with increased risk, whereas two administrations (adjusted OR, 5.43; P=0.005) and three or more (adjusted OR, 3.59; P=0.016) were associated with markedly elevated risk (P for trend=0.002).Conclusions: Peripheral 11.7% HTS was associated with increased phlebitis risk, though cases were predominantly mild. Risk increased with repeated rather than single-dose administration, suggesting caution is warranted when multiple peripheral doses are required.
Objective: Survivors of critical illness commonly experience persistent physical, cognitive, and psychological impairments, collectively known as post-intensive care syndrome. Although intensive care unit (ICU) rehabilitation is now recognized as an important part of recovery after critical illness, rehabilitation practices remain inconsistent, and clinical practice guidelines adapted to the Korean healthcare context have not been available.Methods: These clinical practice guidelines were developed de novo by a multidisciplinary panel comprising critical care physicians, rehabilitation specialists, nurses, and allied health professionals. The panel prioritized 15 key clinical questions addressing adult, pediatric, and neonatal ICU (NICU) rehabilitation. Systematic literature searches were conducted in Medline via PubMed, Embase, the Cochrane Library, and KoreaMed, and the final searches for all 15 questions were completed by November 30, 2024. The certainty of evidence and strength of recommendations were assessed using the Grading of Recommendations Assessment, Development and Evaluation framework. Final recommendations were approved through a structured consensus process requiring at least 70% panel agreement.Results: The panel issued 15 recommendations across major rehabilitation domains, including early structured rehabilitation, criteria for withholding or discontinuing therapy, adjunctive modalities, rehabilitation frequency, inspiratory muscle training, swallowing rehabilitation, cognitive and occupational therapy, nutritional support, neonatal and pediatric ICU rehabilitation, and post-ICU follow-up care. Thirteen recommendations were conditional, whereas two were strong, mainly because they addressed patient safety.Conclusion: These guidelines provide evidence-informed recommendations for rehabilitation in critically ill patients across adult, pediatric, and NICUs in Korea. They are designed to standardize practice, improve patient safety, support patient-centered functional recovery beyond survival, and identify priorities for future research.
Background:Adequate nutritional support is crucial in enhancing clinical outcomes for critically ill patients. The nutrition risk in the critically ill (NUTRIC) score serves as a risk assessment tool to identify critically ill patients at high risk of malnutrition. This score incorporates Interleukin-6 (IL-6) as a key component, which may be costly and less accessible in low- and middle-income countries. Methods:A prospective cohort study of patients admitted to tertiary hospital. IL-6 in the NUTRIC score was replaced by the Prognostic Nutritional Index (PNI) to establish the NUTRIC score incorporating the PNI (NUTRIC-PNI) score. The outcomes are determining the concordance in identifying nutritional risk and comparing the prognostic value between NUTRIC-PNI and NUTRIC scores in predicting 28-day mortality in critically ill patients. Results:A total of 123 patients were analyzed with a median age of 69±16 years old and 72.4% of males. The Cohen's Kappa coefficient of 0.869 indicates strong agreement between the two scoring systems. The NUTRIC-PNI and NUTRIC scores demonstrated comparable predictive accuracy for 28-day mortality, each achieving an area under the curve of 0.68 (95% CI, 0.59-0.78 for NUTRIC-PNI and 0.59-0.77 for NUTRIC; P<0.001. The logistic regression analysis demonstrated that the NUTRIC-PNI and its high-risk classification were independent predictors of 28-day mortality (OR, 1.38; 95% CI, 1.05-1.81; P=0.021 and OR, 4.21; 95% CI, 1.55-11.43; P=0.005, respectively). Conclusions:The concordance and performance of the NUTRIC-PNI score are comparable to the NUTRIC score. Furthermore, the NUTRIC-PNI score and its high-risk classification were independent predictors of 28-day mortality in critically ill patients. In addition to the modified NUTRIC score, the NUTRIC-PNI score is feasible and beneficial for routine clinical practice, particularly in resource-limited settings.
Background:Sepsis is increasingly recognized as a state of profound endothelial dysfunction triggered by infection, leading to microvascular injury and multi-organ failure. Non-invasive assessment of brachial artery reactivity using ultrasound following transient ischemia provides an indirect yet practical tool for evaluating endothelial dysfunction. This study aimed to determine the association between brachial artery reactivity indices and intensive care unit (ICU) mortality in sepsis and septic shock patients. Methods:In this prospective analysis, 120 participants were enrolled, with 40 in each group (sepsis, septic shock, and healthy controls). Within 24 hours of ICU admission, baseline and post-deflation arterial diameters and velocity time integral (VTI) were measured using ultrasonography after three minutes of cuff occlusion at 50 mm Hg above systolic pressure and compared. Subgroup analysis was performed to compare survivors and non-survivors, correlating with Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) scores. Results:Flow mediated dilation (FMD), hyperemic VTI, and change in VTI (ΔVTI) were significantly reduced (P<0.001) in sepsis and septic shock compared with controls. Non-survivors (n=38) had significantly lower hyperemic VTI (53.40 cm/cardiac cycle [interquartile range, 40.28-65.95] vs. 61.30 [48.18-84.85], P=0.041) and lower ΔVTI (35.80 [20.3-43.66] vs. 44.65 [30.95-57.23], P=0.011) than survivors. Receiver operating characteristic analysis showed ΔVTI (cutoff, 43.07 cm/cardiac cycle) had higher specificity (59.5% vs. 54.8%) than hyperemic VTI (cutoff, 60.15), while both showed equal sensitivity (71.1%) for discriminating ICU mortality. Conclusions:Brachial artery reactivity indices were impaired in sepsis and septic shock. Hyperemic VTI and ΔVTI may have potential as complementary bedside prognostic markers requiring further validation in larger multicenter studies.
Background:Refractory ventricular fibrillation (rVF) presents a significant challenge in advanced cardiovascular life support (ACLS), with traditional antiarrhythmics showing limited success in improving long-term survival and neurological function. Esmolol, a beta-1 selective adrenergic receptor antagonist, might offer benefits due to its rapid onset and catecholamine-suppressing effects during cardiac arrest. Methods:This systematic review and meta-analysis (SRMA) evaluates the effectiveness of esmolol in improving the temporary return of spontaneous circulation (ROSC), sustained ROSC, survival to discharge, and survival to discharge with favorable neurological outcomes in rVF patients. This SRMA reviewed Medline (Ovid), Embase (Ovid), and Cochrane Central (Ovid) from their inception until October 2, 2025, for full-text clinical or observational studies assessing esmolol use alongside standard ACLS in adult rVF in both prehospital and in-hospital settings. Results:The risk of bias was independently assessed using the Newcastle-Ottawa Scale. Pooled risk ratios (RRs; 95% CI) are reported. Analyses in which I² >50% used a random-effects model; otherwise, a common-effect model was used. Four studies (n=273) are included. Esmolol was associated with an increased temporary ROSC (RR, 1.80; 95% CI, 1.09-2.98), and although the links were not statistically significant, esmolol trended toward a benefit in sustained ROSC (RR, 1.25; 95% CI, 0.28-5.66), survival to discharge (RR, 1.08; 95% CI, 0.57-2.03), and survival to discharge with favorable neurological outcomes (RR, 2.08; 95% CI, 0.83-5.24). Conclusions:Esmolol was associated with improved temporary ROSC in rVF. The sensitivity analysis suggests potential benefits for sustained ROSC and neurological survival, but more data are needed. Further research is needed to clarify its role.
Background:The global rise in elderly populations has led to increasing admissions of older adults to intensive care units (ICUs). Understanding predictors of mortality in the very elderly is essential, particularly in low- and middle-income countries (LMICs) where ICU resources are limited. Methods:This retrospective observational study analyzed 1,028 ICU patients aged ≥75 years admitted to a level 3 ICU in Nepal. Demographics, comorbidities, frailty score, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, interventions, and outcomes were collected. Univariate analysis, bivariate analysis, and multivariate logistic regression were used for statistical analysis to determine independent predictors of ICU mortality. Results:The cohort had a mean age of 82±5 years and 58.1% were male. ICU mortality was 17.5%. Non-survivors were older and had higher APACHE II scores, more comorbidities, and a greater requirement for mechanical ventilation and vasopressors than survivors. Logistic regression identified age (adjusted odds ratio [aOR], 1.05), comorbidity burden (aOR, 1.40), APACHE II score (aOR, 1.08), mechanical ventilation (aOR, 2.10), and the use of vasopressors (aOR, 1.80) as independent predictors of mortality. Frailty, sex, aggressiveness of therapy, and primary system involvement were not independently associated with ICU mortality. Conclusions:Age, comorbidity burden, and organ support requirements strongly predicted mortality among elderly ICU patients in Nepal. These findings support early risk stratification, prognostic assessment, and informed clinical discussions in resource-limited ICU settings.
Background:Venovenous (VV) extracorporeal membrane oxygenation (ECMO) supports pediatric patients with severe respiratory failure; however, some experience clinical deterioration requiring conversion to venoarterial (VA) ECMO or resulting in mortality. The prognostic role of the vasoactive-inotropic score (VIS) at VV ECMO cannulation remains unclear. Methods:We retrospectively analyzed pediatric patients who underwent VV ECMO between 2010 and 2024 at a single center. Baseline VIS was calculated from vasoactive infusion rates documented immediately prior to cannulation. The primary composite outcome was conversion to VA ECMO or in-hospital mortality. Associations between VIS and outcomes were assessed using correlation, univariable logistic regression, and receiver operating characteristic (ROC) analysis. Results:Twenty patients underwent VV ECMO. Five (25.0%) required VA conversion, seven (35.0%) died, and nine (45.0%) met the composite outcome. Baseline VIS was not significantly associated with isolated mode change (r=0.13, P=0.589) and showed a borderline association with mortality (r=0.43, P=0.062). Logistic regression demonstrated a consistent direction of association between higher baseline VIS and the composite outcome (odds ratio, 1.04; 95% CI, 1.00-1.09; P=0.078). Correlation analysis also suggested an association (r=0.54, P=0.014). ROC analysis demonstrated an AUC of 0.79, suggesting potential discriminative ability, with an exploratory cutoff of 25. Conclusions:Baseline VIS showed a possible association with clinical deterioration in this pilot cohort. These findings are exploratory and require validation in larger prospective multicenter studies.
Background: Critically ill patients often have long-lasting limitations in activities of daily living, particularly in walking ability. Although early mobilization increases the likelihood of independent ambulation at hospital discharge, the timing at which different mobilization levels become associated with ambulatory recovery is unclear. This study describes the timing for achieving several mobilization levels and its associations with ambulatory recovery at hospital discharge.Methods: In this single-center retrospective cohort study, patients were divided into a regained group, composed of patients whose ambulation recovered to pre–intensive care unit (ICU) admission levels by hospital discharge, and a non-regained group. Multivariable logistic regression analyses and receiver operating characteristic curve analyses were performed to examine the association between the timing of mobilization (standing, marching in place, and assisted walking) and regained ambulation at hospital discharge.Results: In total, 295 patients were included, and 223 (76%) of them had regained ambulation at hospital discharge. The adjusted odds ratio for standing peaked on day 10 after ICU admission (odds ratio, 5.61; 95% CI, 2.21–17.76) and declined thereafter. The optimal cutoff time linking marching in place and walking with assistance to regained ambulation was also day 10 after ICU admission (marching in place: area under the curve [AUC], 0.78; sensitivity, 0.83; specificity, 0.64; and walking with assistance: AUC, 0.79; sensitivity, 0.77; specificity, 0.68).Conclusions: The findings suggest that mobility status on day 10 after ICU admission can serve as a pragmatic marker for identifying patients at risk of poor ambulatory recovery.
Background: We developed a novel evaluation for delirium and cognitive function named Jikei Command following Scale (JCoS). The objective of this study was to examine the reliability and validity of the JCoS. Methods: JCoS consists of 8 subitems (1, hand holding and releasing; 2, plantar dorsiflexion; 3, eye opening and closing; 4, visual pursuit; 5, mouth opening; 6, neck movement; 7, two-step command; and 8, movement sustainment). Fifty patients in the intensive care unit (ICU) participated in this study. Cronbach's alpha coefficient of JCoS total score was used for internal consistency. Intraclass correlation coefficient (ICC case 2) was used for inter-examiner reliability. The kappa coefficients for each subitem score were calculated. Concurrent validity was examined by correlation with Confusion Assessment Method for the ICU (CAM-ICU) and intensive care delirium screening checklist (ICDSC). Mini-Mental State Examination (MMSE) 2 weeks after leaving the ICU was used for predictive validity. Results: The Cronbach's alpha coefficient of the JCoS Score was 0.967. The ICC (2,1) of the JCoS Score was 0.933. The kappa coefficients of each subitem were 0.668 for 1, 0.534 for 2, 0.346 for 3, 0.721 for 4, 0.474 for 5, 0.625 for 6, 0.724 for 7, and 0.709 for 8. Correlation coefficient between JCoS and the ICDSC was –0.843, and the correlation ratio between JCoS and CAM-ICU was –0.881. Correlation coefficient between JCoS and MMSE was 0.632. Conclusions: These results suggest that JCoS has sufficient reliability and validity for evaluating about delirium and cognitive function in ICU.
