Pulse oximetry provides a non-invasive numerical estimate of arterial oxygen saturation. It is simple to apply and interpret by clinicians at all levels, and its use has expanded substantially across prehospital care, emergency departments, acute care units, and household monitoring. Although pulse oximetry is portable, non-invasive, and cost-effective, its limitations are clinically important because it measures oxygen saturation rather than ventilation, oxygen delivery, or tissue oxygen utilization. Over-reliance on SpO₂ values for decisions related to oxygen administration, escalation of care, and clinical deterioration may conceal subtle but serious abnormalities. This review discusses the limitations of pulse oximetry in emergency and acute care settings, including sepsis, regional hypoperfusion, dyshaemoglobinemias, COVID-19, pulmonary embolism, hyperoxia, skin pigmentation-related bias, and other relevant clinical contexts. The central message is that SpO₂ should be interpreted as one component of a broader assessment bundle and should not substitute for comprehensive clinical evaluation.
Severe acute Valproic Acid (VPA) ingestions may require intensive care, intubation, or Extracorporeal Treatments (ECTRs), but early predictors are poorly defined. In this study we aimed to identify presentation features associated with Intensive Care Unit (ICU)-level care, intubation, and ECTRs after VPA exposure. We analyzed 164 VPA cases reported to the Toxicology Investigators Consortium Core Registry from January 1, 2012, through December 31, 2025. Candidate predictors were selected a priori from severe VPA toxicity features. Associations were assessed using Fisher exact tests and Odds Ratios (ORs). Median age was 34.5 years; 144/164 exposures (87.8%) were intentional. ICU-level care occurred in 49/164 cases (29.9%), intubation in 23/164 (14.0%), and ECTRs in 5/164 (3.0%). ICU-level care was associated with respiratory depression (OR 30.0), metabolic acidosis (OR 15.9), hypotension (OR 4.63), central nervous system depression (OR 4.23), and co-ingestion (OR 3.25). Therapeutic-use cases were less likely to require ICU-level care or intubation. Respiratory depression, metabolic acidosis, hypotension, central nervous system depression, and co-ingestion identify VPA exposures at higher risk for ICU-level care.
The recent tragic death of a young man experiencing hyperactive delirium with severe agitation in Bologna (Italy), on July 19, 2026,1 should serve as a crucial reminder of the importance of effective management of this challenging emergency. While it is a tragic event, the shock of such an episode forces us to draw a core lesson for clinical practice, system design, and medical culture. Hyperactive delirium with severe agitation is indeed a true medical emergency.2 Individuals usually experience extreme agitation characterized by unexpected strength, panic, violence, disorientation, hallucinations, hyperthermia, and an accelerated autonomic nervous system. These symptoms can quickly escalate and lead to cardiopulmonary arrest, often resulting in the patient's death, frequently occurring in a pre-hospital care setting. [...]
Early mortality after trauma is a major concern in emergency care. This study aimed to compare deaths occurring within the first 24 hours with those occurring later using statistical analysis and supervised machine learning, and to assess the effect of class imbalance on model performances. This retrospective study included all consecutive trauma deaths recorded between May and August 2021 in the hospital information system of a tertiary care training and research hospital. The cohort was restricted to patients who died during hospitalization because the aim was to distinguish mortality timing among fatal trauma cases rather than to predict mortality versus survival. Mortality time was classified as death within 24 hours or death after 24 hours from emergency department admission. Clinical, laboratory, and injury-related variables were analyzed using univariate tests. Multiple supervised machine learning models were trained with a stratified 80:20 train/test split and evaluated by AUC. Five resampling techniques were employed to address class imbalance. Hemoglobin and hematocrit differed significantly between early and late mortality groups (p<0.05), and injury patterns were associated with mortality timing. In imbalanced data, Support Vector Machine achieved the highest AUC (0.800). After resampling, Gaussian Naive Bayes combined with ADASYN showed the best performance (AUC=0.847). These findings suggest that mortality timing among fatal trauma cases can be explored using supervised machine learning; however, the retrospective single-center design, modest sample size, class imbalance, and exclusion of survivors limit direct applicability to real-time emergency department triage. The model should therefore be interpreted as an exploratory mortality-timing classifier rather than as a general trauma mortality prediction tool.
Gastrointestinal (GI) perforation in association with COVID-19 is uncommonly reported in the literature. In this study, our goal was to elucidate the possible pathologic role of SARS-CoV-2 on the GI tract in a patient suffering from intestinal perforation. A literature review using PubMed identified 40 additional cases of COVID-19-related GI perforation. Including our case, a total of 41 cases has been described in the literature, 18 of which were fatal. Including our case, in only three cases SARS-CoV-2 RNA was detected in intestinal surgical specimens. The detection of Sars-Cov-2 viral RNA in GI tissue samples has not been adequately standardized, and consistent results are lacking. Regular testing for SARS-CoV-2 in biopsy and surgical specimens would be necessary to establish its true, direct pathological role in the GI manifestations associated with COVID-19, also in those patients with severe illness or on treatments like glucocorticoids and tocilizumab.
In patients presenting to the Emergency Department (ED) with acute respiratory symptoms or suspected infection, Lung Ultrasound (LUS) may serve as a valuable diagnostic tool. Its use and clinical applicability markedly increased since the SARS-CoV-2 pandemic. The aim of this study was to evaluate whether LUS can predict 30-day mortality or Intensive Care Unit (ICU) admission in patients presenting to the ED and to develop a prognostic model. We conducted a bicentric observational cohort in two Italian EDs. Two scores were analyzed, the overall LUS score and the anterolateral LUS score. Multivariable logistic regression models were developed, and their performance was assessed using the area under the receiver operating characteristic curve (Area Under the Curve, AUC) and validated with concordance indices (C-indexes). Four hundred and thirty-four patients were enrolled. The median time from symptom onset to ED presentation was 4 days (IQR 6). The primary final diagnosis was SARS-COV2 infection in 32% of cases, other respiratory diseases in 15%, heart failure in 9%. The composite outcome occurred in 68 patients (15.7%). The empirically estimated AUC of the LUS score was 67%. A prognostic model including age, overall LUS score, time from symptom onset, history of diabetes, chronic kidney disease, and cancer within the previous 5 years showed a C-index of 70.8%. This study suggests that, in patients presenting to the ED with respiratory symptoms, the LUS score may have a prognostic value regardless of the final diagnosis established at the end of the diagnostic work-up performed in the ED.
Renal artery in-stent restenosis is an uncommon but serious cause of resistant hypertension and flash pulmonary edema. We present the case of a 75-year-old woman with extensive multidistrict atherosclerosis and a history of multiple endovascular procedures, who presented to the emergency department with recurrent pulmonary edema due to uncontrolled hypertension. Despite maximal antihypertensive therapy, her blood pressure remained severely elevated, with evidence of acute kidney injury. Doppler ultrasound revealed restenosis of the right renal artery stent, characterized by a tardus-parvus waveform, along with an atrophic left kidney. The patient underwent successful right renal artery lithotripsy and stenting, resulting in restoration of renal perfusion and subsequent improvement in blood pressure control and pulmonary congestion. In patients with resistant hypertension and recurrent flash pulmonary edema, prompt recognition of renal artery stenosis, the so-called Pickering syndrome, or in-stent restenosis as in the present case, and timely endovascular reintervention can be lifesaving.
Pediatric Out-Of-Hospital Cardiac Arrest (OHCA) is a rare but devastating event with an incidence of less than 10 cases per 100,000 population. We present a case of exercise-induced cardiac arrest in a previously healthy adolescent athlete, ultimately diagnosed with an anomalous origin of the left coronary artery. A 12-year-old athletic boy with no significant medical history experienced syncope at the finish line of a 3000-meter race. Initial assessment revealed severe hemodynamic instability progressing to cardiac arrest (bradycardic pulseless electrical activity) requiring cardiopulmonary resuscitation. Return of spontaneous circulation was achieved after 4 minutes. The patient subsequently developed acute pulmonary edema requiring emergency intubation. Cardiac computed tomographic angiography revealed an anomalous left coronary artery originating from the right coronary ostium with a malignant inter-arterial course. The patient underwent successful surgical reimplantation of the left coronary artery. He was discharged after 18 days with no neurological sequelae and subsequently returned to competitive sports with cardiologic clearance. This case highlights the importance of rapid emergency response and comprehensive diagnostic evaluation in young athletes presenting with exercise-induced cardiac events. Anomalous coronary arteries should be considered in the differential diagnosis of exercise-related syncope or cardiac arrest in seemingly healthy young individuals.
Background. Fat Embolism Syndrome (FES) is a rare but potentially fatal complication in patients with Duchenne Muscular Dystrophy (DMD), particularly after long bone fractures. DMD patients are predisposed to osteoporosis and traumatic fractures due to chronic corticosteroid therapy, loss of ambulation, and obesity. Clinical diagnosis of FES remains challenging, as radiological findings are often inconclusive and treatment is mainly supportive. We describe a case of a child with DMD who developed fatal FES after low-energy trauma. Methods. We describe the clinical course of a 13-year-old boy with genetically confirmed DMD who was admitted to our Intensive Care Unit following a wheelchair fall that caused femoral and tibial fractures. Clinical data, laboratory findings, imaging studies, and therapeutic interventions were analyzed. Diagnostic criteria were compared with Gurd’s major and minor signs. Results. The patient presented with rapid neurological deterioration and hypoxemia shortly after trauma. Initial CT imaging was unremarkable, but MRI revealed multiple microembolic ischemic lesions in basal ganglia and cortical territories. Laboratory evaluation demonstrated anemia, thrombocytopenia, elevated D-dimer, and high troponin levels. Clinical progression was characterized by petechial rash, worsening respiratory failure, and hemodynamic instability requiring mechanical ventilation and vasoactive support. Despite aggressive treatment with protective ventilation, corticosteroids, anticoagulation, osmotherapy, and orthopedic stabilization, the patient developed cerebral edema, fixed mydriasis, and eventually cardiogenic shock leading to death within four days. Post-mortem examination was arranged to confirm fat embolism. Conclusions. This case highlights the diagnostic and therapeutic challenges of FES in pediatric DMD patients. The combination of multiple long bone fractures, rapid neurological decline, petechiae, and respiratory compromise strongly supported the diagnosis. Preventive strategies, including careful patient handling, fracture stabilization, and cautious fluid management, remain crucial as therapeutic options are limited and largely supportive. Clinicians should maintain a high index of suspicion for FES in DMD patients with fractures, as delayed recognition may contribute to poor outcomes. Further studies are required to evaluate preventive measures and potential pharmacological interventions such as corticosteroids, statins, or albumin therapy.
Introduction. Flexible Bronchoscopy (FBS) is an essential diagnostic-therapeutic procedure in critical care, useful for treating airway obstructions and respiratory infections, in microbiological sampling and optimisation of diagnostic and therapeutic strategies. In literature it is demonstrated that FBS performed in Emergency Department (ED) and in Sub-Intensive Care units (SICU), when carried out by trained emergency physicians in an appropriate setting, improves clinical outcomes with a low complication rate. Based on this evidence, we developed a project to implement FBS within A&E and SICU of our hospital, which lacks a dedicated endoscopic service. Methods. The study began in March 2025 with the development of a structured theoretical and practical training program for a multidisciplinary team of physicians, nurses, and Healthcare Assistants (HCA) working in sub-intensive care, enabling them to perform FBS in emergency settings. FBS was carried out within approximately 72 hours from patient’s admission to ED or SICU, using a dedicated room equipped with both reusable and single-use flexible bronchoscopes, a video monitor, suction system for microbiological sample collection, and continuous multi-parameter monitoring. In each procedure two teams were involved: one team responsible for performing FBS, consisting of two physicians, one nurse and one HCA; another dedicated to sedation and patient monitoring composed by one emergency physician and one nurse. For each patient, data were collected regarding indication, characteristics and timing of procedure, use of procedural sedation, diagnostic outcome and possible complications. Finally, the study evaluated the impact of this procedure on the diagnostic and therapeutic handling of the patient. Results. From 12 March 2025 to 28 October 2025 21 bronchoscopies were performed. The results are reported in the table below. The average procedural time was approximately 16 minutes and all complications were mild, temporary, and self-limiting, with no major adverse events reported (pneumothorax, severe hemodynamic instability, refractory hypoxemia, or early post-procedural death). Each procedure was preceded by procedural sedation allowing an average level of sedation between –2 and –3 according to the Richmond Agitation Sedation Scale (RASS) without any significant adverse event. Bronchoalveolar Lavage (BAL) yielded significant cultures in 75% of cases, leading to the adjustment of antibiotic therapy in 40% of patients and a reduction in oxygen requirement. Conclusions. Our experience confirms that FBS performed in the ED/SICU is a safe and effective procedure that enables timely targeted antibiotic therapy, improving clinical outcomes and the overall efficiency of the clinical care pathway. Observed complications were minimal, demonstrating that bronchoscopy carries no significant risk when performed by trained staff in an organised and well-equipped setting. Moreover, the ability to perform the procedure directly in peripheral settings ensures faster and more timely treatment of the condition, without the need to arrange transfers of critically ill and unstable patients to Hub centres, which can thus be restricted to second-level procedures or cases with high clinical risk.
Background. We conducted a prospective observational study conducted in two tertiary hospital ICUs to evaluate heart hemodynamics in septic shock. The primary objective is to evaluate the relationship between Arterial Compliance Pressure (ACP) measured by the PiCCO system and Ventricular-Arterial (VA) coupling obtained by echocardiography to predict Septic Cardiomyopathy (SCM) within the first 48 hours of septic shock diagnosis. Methods. The study enrolled 13 adult patients diagnosed with septic shock, undergoing semi-invasive hemodynamic monitoring (PiCCO, MostCare) within the first 48 hours. Patients were evaluated at baseline (<12h from diagnosis), 72 hours, and 7 days. Data collected included demographic information, clinical parameters, and echocardiographic measurements. ACP was calculated as a percentage value of the ratio between Cardiac Index (CI) measured with the PiCCO system and predicted CI. Echocardiographic evaluation focused on systolic and diastolic function of the cardiac sections and VA coupling. Results. At baseline, 30.77% of patients met the criteria for SCM, which increased to 38.6% at three days. By the seventh day, an improvement in hemodynamic parameters was observed in 62% of patients. The study found a significant association between ACP and VA coupling at baseline (R²=0.34; p=0.003). Both ACP and VA coupling metrics were valid in predicting SCM, with ACP showing a slightly higher area under the ROC curve. The study also noted a trend of improvement in both PiCCO and echocardiographic parameters over the seven days. Conclusions. The preliminary findings suggest that both ACP and VA coupling are effective in predicting SCM in septic shock patients. The improvement in hemodynamic parameters over seven days indicates potential for better patient outcomes with early and accurate monitoring. Further research with a larger sample size is needed to validate these results.
Dear Editor, We were very intrigued to read about the "decalogue" by Cipriano et al. that provides a plan to respond to the continuing problem of overcrowding and operational stress experienced within Emergency Department (ED). They present a well-timed, organized, structured plan that includes a number of systems-level recommendations to help reduce the persistent problem of overcrowding and operational stress in EDs.1 While the strategies included in their article have significant relevance to high-resource settings, each strategy needs to be considered carefully for Low- and Middle-Income (LMIC) settings, as there are important contextual differences for LMIC settings when compared with high-resource settings. [...]
Background. The rationale for using albumin in fluid resuscitation lies in its ability to increase plasma oncotic pressure and optimize hemodynamics and tissue perfusion. However, randomized trials in sepsis have not demonstrated a survival benefit, and the effects of albumin infusion on fluid distribution remain unclear. This study investigates, in healthy pigs, whether albumin infusion modifies Intravascular Fluid Volume (IFV) distribution, compared to crystalloids, and explores albumin kinetics. Methods. Thirty-nine healthy female pigs ventilated for 48 hours were categorized into four groups based on Mechanical Power (MP) (High ~18 J/min vs. Low ~6 J/min) and fluid type (5% albumin vs. balanced crystalloid) to achieve a set fluid balance: MPLOW-Crystalloid; MPLOW-Albumin; MPHIGH-Crystalloid; and MPHIGH-Albumin. Measurements were taken at baseline and six-hourly thereafter. Outcome variables included IFV and albumin kinetics and other physiological variables. Results. No significant differences in IFV were observed over time across groups (Figure 1), and at 48 hours: MPLOW-Crystalloid 1.92 (±0.38) L; MPLOW-Albumin 1.86 (±0.37) L; MPHIGH-Crystalloid 1.72 (±0.40) L; MPHIGH-Albumin 2.10 (±0.58) L; p=0.389. As expected, the theoretical and the actual quantities of albumin in the IFV were higher in the albumin groups compared to the crystalloid groups. Wasted albumin, defined as the difference between theoretical and actual albumin is shown in Figure 2. At 48h, albumin-treated groups demonstrated significantly greater albumin waste, as high as: 62 (±13) % in the MPLOW-Albumin group and 58 (±24) % in the MPHIGH-Albumin group (p<0.001). Groups receiving albumin had a higher volume of ascites: MPLOW-Crystalloids =261 (±380) mL, MPLOW-Albumin =710 (±664) mL, MPHIGH-Crystalloids =144 (±148) mL, and MPHIGH-Albumin =685 (±651) mL (p=0.034) (Figure 3, Panel A). Additionally, the amount of infused albumin was linearly related to the volume of ascites (p<0.001; R2=0.750) (Figure 3, Panel B). Conclusions. The 48h-long administration of albumin was associated with higher quantities of wasted albumin and greater volume of ascites.
Background. Sedation in patients with moderate-to-severe ARDS due to SARS-CoV-2 pneumonia requires precise titration to ensure adequate control of respiratory drive and comfort while maintaining hemodynamic stability and optimizing gas exchange. Volatile agents such as Sevoflurane are gaining interest in intensive care as alternatives to intravenous sedatives, due to their bronchodilatory, anti- inflammatory, and lung-protective properties, as well as their favorable pharmacokinetic profile. Advanced monitoring systems now allow continuous assessment of hypnotic depth and nociceptive balance during inhalational sedation—an approach still not widely applied in this setting. Case Presentation. In the ICU of the University Hospital of Sassari, we report the case of a 75-year-old male (BMI 29.3) with major depressive disorder admitted for acute respiratory failure due to SARS-CoV-2 pneumonia (PaO₂/FiO₂ =131 mmHg). The patient initially received propofol and morphine; however, due to worsening oxygenation and bronchoconstriction, neuromuscular blockade with cisatracurium was initiated. Propofol was then replaced with Sevoflurane administered via the MIRUS system for 72 h. Continuous Depth-of-Anesthesia (qCON) and Nociception (qNOX) monitoring were implemented. With a MAC of 0.7, achieved through concomitant opioid use, qCON values(51.5 [50-55]) and qNOX(35 [33-36]), remained within the target range for adequate sedation and analgesic levels. During sevoflurane administration, a marked improvement in gas exchange was observed (PaO₂/FiO₂ from 131 to 201 mmHg), along with enhanced ventilatory mechanics and stable hemodynamics (MAP 70 [70–75] mmHg) despite pulmonary sepsis. No relevant cardiovascular or neurological adverse effects occurred. Results. This case demonstrates the feasibility and clinical benefit of sevoflurane sedation in ARDS, with improved oxygenation, pulmonary mechanics, and preserved hemodynamic stability. The association of the volatile agent with an opioid allowed the maintenance of lower MAC values while ensuring adequate hypnotic depth and nociceptive control, optimizing both sedation quality and physiological tolerance. Conclusions. Based on this experience, we aim to develop a pilot study evaluating the physiological effects of sevoflurane focusing on respiratory drive modulation, bronchodilation, gas exchange efficiency, and hemodynamic stability ARDS. Given that volatile anesthetics also exert cardiocerebral protection and anti-inflammatory actions beyond sedation, this research could validate their role as multimodal, targeted therapies in critical care.
Background. Clinical simulation has become an essential educational strategy in critical care settings, promoting the development of technical and non-technical skills such as communication, leadership, and stress management. While its professional benefits are well documented, little is known about the impact that simulation-based training can have on education in critical care. This study aims to evaluate the perceived impact of simulation training on critical care healthcare professionals, focusing on professional competence and development of non-technical skills. Methods. An observational cross-sectional study was conducted using a structured questionnaire consisting of 22 multiple-choice items, administered with Google Forms to attending physicians, medical residents, and nurses, working in various critical care services (intensive care units, emergency departments, pre-hospital emergency services). The survey included questions on the following domains: The professional impact of technical and non-technical skills and the extent to which simulation can improve emergency/urgency management The personal and emotional impact of simulation: how it improves stress management in critical situations and highlights the need for continuous training Results. This observational cross-sectional study included 103 critical care healthcare professionals (physicians, residents, and nurses). The vast majority of participants (81.6%) perceived the impact of simulation on their work as "High" to "Very High", with 53.4% choosing the maximum rating ("Very High") [Figure 1]. In line with the study's objective, the analysis confirmed a strongly perceived impact on skill improvement: Technical Skills: 79.6% of participants rated the improvement of technical skills with a score of 4 or 5 out of 5 (54.4% maximum rating) [Figure 2A]. Non-Technical Skills: The effectiveness in improving non-technical skills (communication and teamwork) was perceived as even higher, with 87.4% assigning a score of 4 or 5 (61.2% maximum rating) [Figure 2B]. Finally, the most useful element in the simulation experiences was found to be the Debriefing, indicated by 48.5% of professionals, surpassing both technical skills alone (31.1%) and non-technical skills alone (18.4%) [Figure 3]. Conclusions. The findings underline how contemporary simulation activities have an extremely positive impact on critical care staff. This strongly perceived impact validates simulation as a central training strategy, essential for advancing professional competence and team effectiveness within the critical care environment.
Background. Advances in diagnostics and therapy have markedly improved the survival of patients with congenital heart disease, many of whom reach adulthood. However, those with uncorrected lesions remain at high risk of cardiopulmonary decompensation. In the setting of refractory hypoxemia and cardiogenic shock, Extracorporeal Membrane Oxygenation (ECMO) may provide life-saving support. The choice between Veno-Venous (V-V) and Veno-Arterial (V-A) configuration must be guided by the underlying cardiac anatomy and shunt physiology. Methods. In the ICU of the University Hospital of Sassari, a 60-year-old woman with uncorrected Tetralogy of Fallot (TOF), palliated by valvulotomy and Blalock-Taussig shunt in infancy, was admitted with bilateral pneumonia and ARF. Her history included severe COPD and refusal of definitive correction in 2023. Despite broad-spectrum antibiotics and non-invasive ventilation (CPAP, HFNC), oxygenation worsened (PaO₂/FiO₂≈50) leading to respiratory arrest and cardiogenic shock. Echocardiography revealed right ventricular dilation and dysfunction, a perimembranous Ventricular Septal Defect (VSD) with right-to-left shunt, and severe infundibular pulmonary stenosis (mean gradient 56 mmHg). Results. Given the presence of an intracardiac shunt, V-V ECMO was contraindicated as it would have worsened systemic hypoxemia by recirculating poorly oxygenated blood through the right-to-left pathway. Peripheral V-A ECMO was therefore initiated via femoral vessels (flow 50-60% of theoretical). Inotropic and vasopressor support (dobutamine, norepinephrine, vasopressin) were gradually tapered as hemodynamic stabilized. Under analgosedation and protective ventilation, gas exchange and systemic oxygenation improved. Neurological function remained intact. Minor mucosal bleeding and transient atrial fibrillation were managed conservatively. After four days, with stable hemodynamic and improved inflammatory indices, the patient was safely transferred to a referral cardiac surgery centre. Conclusions. In adults with uncorrected TOF and right-to-left shunt, severe hypoxemia secondary to pneumonia may mimic isolated respiratory failure, but V-V ECMO can exacerbate desaturation. V-A ECMO provides both circulatory support and systemic oxygen delivery; however, due to complex cardiopulmonary physiology and potential flow inversion associated with changes in pulmonary vascular resistance, its application does not necessarily guarantee immediate improvement in oxygen saturation. In non-cardiac surgery centers, early recognition of shunt dynamics and tailored ECMO strategy are essential to ensure stabilization and improve survival in this high-risk population.
Background. Chest pain is a frequent symptom encountered in the Emergency Department (ED), with a mortality rate of 2-4%. It may reflect a wide range of clinical conditions, from benign issues to life-threatening Cardiovascular (CV) diseases. Alongside conventional clinical tools and various validated scores, Artificial Intelligence (AI) systems are emerging as potential aids for appropriate risk stratification. Methods. A sample of 154 patients who presented to the ED of the Pisa University Hospital (AOUP) between May 2024 and June 2025 for chest pain was analyzed to evaluate the diagnostic accuracy of the ChatGPT 4.0 algorithm. For each patient, management, final diagnosis, and outcomes were reviewed. A limited number of variables were selected and submitted to the algorithm in two sequential queries: the first included triage data (demographics, sex, vital signs, medical history, and pain characteristics), while the second included physical examination findings, laboratory tests, and imaging results. Results. The study population had a mean age of 60.7 years. Life-threatening conditions accounted for a clear minority of cases (17.45%). Most patients (74.5%) were discharged home after negative diagnostic evaluations. The results concerning diagnostic accuracy between the final clinical diagnosis and the AI-suggested diagnosis showed, in the first query (triage data), a concordance of 32.9% when considering only the first proposed diagnosis and 67.8% when considering the top three suggestions. In the second query (which incorporated laboratory and instrumental data), accuracy increased to 90.6%. Similarly, the algorithm’s ability to correctly identify exclusively acute CV conditions (pulmonary embolism, acute coronary syndrome, and aortic dissection) reached 100%. Conclusions. AI demonstrated an ability to recognize relevant diagnostic patterns, particularly when provided with well-structured inputs. The promising results obtained open concrete possibilities for using AI systems in triage and early evaluation of chest pain, potentially leading to purpose-built algorithms capable of integrating directly with hospital information systems.
Introduction. The new global definition of Acute Respiratory Distress Syndrome (ARDS) allows diagnosis in patients receiving High-Flow Nasal Cannula (HFNC) therapy at flow rates ≥30 L/min and supports the SpO2/FiO2 (S/F) ratio as an alternative to the PaO2/FiO2 (P/F) ratio. It also recognizes Lung Ultrasound (LUS) as an imaging modality equivalent to CT or chest X-ray for identifying bilateral opacities, emphasizing its value for dynamic bedside monitoring of disease progression and recovery. We report a case of Fat Embolism Syndrome (FES) evolving into moderate ARDS, managed exclusively with HFNC and monitored through an integrated ultrasonographic approach. Methods. A 16-year-old male was admitted to the Intensive Care Unit (ICU) for hypoxemia that developed after a post-traumatic diaphyseal femur fracture. On admission, on spontaneous ventilation before the initiation of HFNC, the S/F ratio was 224. Chest CT revealed bilateral alveolar infiltrates consistent with ARDS. HFNC was started (initial flow 55 L/min, FiO₂ 0.5), with serial monitoring of P/F and S/F ratios. A systematic 8-zone diagnostic lung ultrasound was also performed with a convex low frequency probe and the lung ultrasound computed for each zone. Results. Following HFNC initiation, oxygenation progressively improved. The P/F ratio increased from 138 to 262 mmHg, while the S/F ratio rose from 186 to 306, with parallel trajectories accompanying the gradual reduction of support (Figure 1) and the HFNC flow was decreased from 60 to 40 L/min in accordance with clinical and gasometric improvement. Lung ultrasound demonstrated a distinct interstitial pattern with multiple B-lines with a global LUS score of 14, consistent with CT and chest X-ray findings (Figure 2). The clinical course was favorable, with complete HFNC weaning by day 5 and discharge on day 6. Conclusions. Implementation of the new global definition is especially useful in post-traumatic ARDS in young patients, for whom a tube-sparing strategy is encouraged - and in resource-limited settings with restricted access to blood gas analysis and imaging. Benefits are also envisaged in terms of limiting serial arterial blood gas sampling and iatrogenic anemia in the ICU. This case exemplifies its practical application, showing how integrating HFNC, S/F ratio, and lung ultrasound enables early diagnosis and effective non-invasive management.
Background. Early Extubation (EE) is a fast-track surgery strategy aimed at enhancing recovery after Orthotopic Liver Transplantation (OLT). The aim of this study was to compare EE in the Operating Room (OR) with Delayed Extubation (DE) in the Intensive Care Unit (ICU), in terms of patients’ clinical characteristics and outcomes. Methods. This retrospective single-center study included adult patients who underwent deceased-donor OLT between April 2024 and December 2024, excluding those with portopulmonary or hepatopulmonary syndrome. Patients extubated in the OR (EE group) and those extubated in the ICU (DE group) were compared regarding transplant indication, norepinephrine dose and lactate levels at the end of surgery, organ-related complications, and hepatorenal function (AST/ALT, total bilirubin, INR, creatinine) on postoperative day 7, ICU and hospital length of stay, and mortality. Data were extracted from the multicenter registry PROSAFE, Petalo Trapianti di Fegato (GiViTI),and analyzed using the Kruskal–Wallis test for continuous variables and the chi-square test for categorical variables (α=0.05). Results. Of the 43 patients who underwent OLT, 37 were enrolled: 59% in the EE group and 41% in the DE group. The two groups were comparable in terms of transplant indication. At the end of surgery, the DE group showed higher norepinephrine requirements (0.16 vs 0.04 mcg/kg/min; p<0.001) and lactate levels (6.6 vs 3.9 mmol/L; p=0.016). Mechanical ventilation weaning was completed within the first 24 hours in the ICU. No significant differences were observed in graft dysfunction, hepatorenal function, or ICU complications, although the EE group showed a higher reintubation rate (13.3% vs 0%; p=0.078). ICU length of stay was longer in the DE group (4.4 vs 2.4 days; p=0.05), whereas hospital length of stay and ICU mortality were similar between groups. Conclusions. Delayed extubation after OLT is reserved for patients with hemodynamic instability at the end of surgery and does not appear to be associated with early complications. Further studies with larger sample sizes are needed to better define criteria for early extubation and assess its impact on hospital resource utilization.
The initial assessment and stabilization of a traumatized patient is of paramount importance. Post-traumatic infections have long been considered among the leading causes and contributing factors of outcomes such as mortality, complications, and Length Of Hospital Stay (LOHS). This is an observational study using data prospectively collected within the "trauma registry" database of the General and Emergency Surgery department of the Pisa University Hospital - Trauma Center of Cisanello (Pisa), collected from November 2019 to December 2021. Epidemiological, clinical and microbiological data have been registered for all patient. Details regarding those who developed infections were analyzed. Among the 533 patients examined, 75 people developed an infection (signs like fever, WBC count increase, infectious protein related) with at least one positive microbiological isolate during hospitalization, for a total of 234 positive isolates, among which pathogens Resistant (R) to one class of antimicrobials and pathogens resistant to more than three classes of antimicrobials (Multi-drug Resistant, MDR) were identified. Multivariate analyses were performed to correlate trauma severity (Injury Severity Score, ISS), general population characteristics and microbiological patterns with outcomes. The presence of resistant strains identified in the second culture test together with ICU admission were found to be risk factors associated to the development of complications. Microbiological patterns were not statistically significant risk factors for mortality. A multidisciplinary team plays a pivotal role in defining the correct antibiotic stewardship program.
