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.
