Nosocomial infections are common in patients receiving extracorporeal membrane oxygenation (ECMO), with ECMO cannula-site infections (ECMO-CSI) being the most frequent infections directly related to the ECMO run. These infections can significantly impact patient outcomes. Currently, no adult guidelines exist for the prevention, diagnosis, and/or treatment of peripheral ECMO-CSI, resulting in heterogeneity in both clinical practice and research findings. We conducted a Delphi study involving 39 international experts in ECMO management. The experts participated in four Delphi rounds to reach consensus on various aspects of ECMO-CSI complicating peripheral ECMO (central ECMO excluded), including definition, clinical suspicion, diagnostic methods, preventive measures, and treatment. Consensus was defined as ≥ 70

OBJECTIVE:A definition of refractory septic shock is necessary to guide diagnosis, management, prognostication, research, and future guidelines for this most severe form of the disease. We sought to achieve consensus on clinical criteria that would be used to define refractory septic shock. DESIGN:Review of literature, expert panel position statements, and Delphi rounds with an international expert group. SETTING:Consensus was defined as having at least 75% of panellists in agreement or disagreement on the three highest or lowest levels of a 7-point Likert scale or based on responses to single- or multiple-choice questions, respectively. SUBJECTS:A panel of multinational, multiprofessional and multidisciplinary critical care experts assembled by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine (57 invitations and 56 participants). MEASUREMENTS AND MAIN RESULTS:A five-round Delphi process was conducted for consensus and stability. The steering committee proposed 34 statements, and five of them were rejected by panel experts after round 2. Among 29 statements selected from eight domains, consensus was reached for 13. The panel agreed on the need for a comprehensive consensus set of clinical criteria for refractory septic shock. Markers of organ dysfunction (75%, 2 rounds), tissue perfusion (91.1%, 2 rounds) including lactate (94.6%, 2 rounds) and capillary refill time (76.8%, 2 rounds), assessment of fluid-responsiveness after initial resuscitation (92.9%, 5 rounds), and use of vasoactive drugs at norepinephrine equivalents greater than 0.5 µg/kg/min (75.0%, 3 rounds), were selected as clinical criteria of refractory septic shock. The use of critical care ultrasound (CCUS) (92.9%, 3 rounds) was the single diagnostic modality that reached a consensus-based agreement. CONCLUSIONS:A consensus for 13 criteria to frame the definition of refractory septic shock was reached. Refractory septic shock is characterised by persistently elevated lactate concentrations and or prolonged capillary refill time in patients with septic shock who are fluid unresponsive, require a norepinephrine base equivalent dose greater than 0.5 micrograms per kilogram per minute, and undergo CCUS assessment when mixed shock is suspected.

A dysregulated host response to infection is central to the pathophysiology of sepsis and may culminate in life-threatening organ dysfunction. Given that this process is largely characterized by concurrent pro- and anti-inflammatory activation, immunomodulatory strategies have long been explored in sepsis research. Among these, extracorporeal removal of circulating cytokines, inflammatory mediators and other soluble factors through non-specific hemoadsorption with macroporous styrene-divinylbenzene sorbents has been proposed as a potential therapeutic approach. Its adoption into clinical practice has largely been based on pathophysiological considerations rather than on evidence from large, well-designed randomized clinical trials. Over the past 15 years, most of the available evidence has been predominantly derived from small, single-center cohorts, reports from registries and heterogeneous prospective studies with substantial variability in patients’ selection, timing, and treatment intensity. In addition, the precise mechanisms of action of hemoadsorption remain incompletely understood. Although several meta-analyses have attempted to synthesize the existing data, the overall quality and heterogeneity of the included studies limit the strength and reliability of their conclusions. As a result, current guideline recommendations are largely based on expert opinions rather than high-certainty evidence. This position statement aimed to provide a concise overview of the biological rationale, current evidence, and contemporary clinical practice related to hemoadsorption in critically ill patients.

Critical illness is characterised by activation of the sympathetic nervous system which plays an important adaptive role in maintaining cardiovascular stability and organ perfusion. However, excessive sustained adrenergic stimulation may become maladaptive, contributing to tachyarrhythmias, myocardial injury, immune dysregulation, metabolic derangements, and organ dysfunction. This state-of-the-art review evaluates the role of ß-blocker therapy as a potential strategy to modulate or counteract the adrenergic response in critically ill patients. Current data suggest that their use remains highly context-dependent and controversial. There are established benefits in selected scenarios, including acute myocardial infarction, tachyarrhythmias, hypertensive emergencies, thyroid storm, and prevention of variceal bleeds. In contrast, evidence is limited or conflicting in septic shock, traumatic brain injury, acute heart failure, burns and other critical care syndromes. Concerns include impairment of compensatory cardiovascular responses, reduction of cardiac output, hypotension, and compromised organ perfusion. Furthermore, the safety and efficacy of ß-blockade appear to depend on the type and dose of ß-blocker, patient phenotype, timing of initiation, hemodynamic reserve, and whether therapy represents continuation of chronic treatment, withdrawal and re-initiation, or de novo initiation during acute illness. This review highlights major gaps in knowledge, including the absence of reliable indicators to identify patients most likely to benefit, uncertainty regarding optimal treatment targets and monitoring strategies, and limited randomised evidence in heterogeneous ICU populations. A phenotype-driven, physiology-guided approach that accounts for hemodynamic status, sympathetic spectrum and timing of ß-blocker therapy is likely required to optimise outcomes.

Background Generative artificial intelligence (GenAI) is increasingly used for clinical decision support in critical care, yet standardized methods for evaluating GenAI content in intensive care settings are lacking. Existing metrics assess textual similarity but fail to capture clinical accuracy, reasoning quality, or urgency. Methods We developed and validated the IMPACT framework through a five-phase multinational panel consensus process. Reporting adhered to the ACCORD guideline. A steering committee of eight persons provided clinical and methodological oversight. Panelists were recruited through purposive sampling to ensure geographic and multidisciplinary representation. Content validity was assessed using the Content Validity Ratio (CVR) and Item-level Content Validity Index (I-CVI), with retention thresholds set at 70% agreement and I-CVI ≥0.80. Results A total of 58 panelists from 12 countries and regions participated, with 42 completing formal consensus voting. Participants included intensivists, physicians with AI research expertise, information technology specialists, and other critical care professionals. All six IMPACT domains exceeded validity thresholds (mean agreement 89.3%, CVR = 0.79, I-CVI = 0.92). Of 24 candidate subitems, 21 met retention criteria (mean agreement 85.7%, CVR = 0.71, I-CVI = 0.90). Three subitems were removed due to insufficient consensus and conceptual overlap. The validated framework comprises six domains with 21 subitems. Conclusions The IMPACT framework provides a consensus-validated approach for evaluating GenAI clinical decision support in intensive care, addressing gaps in current evaluation methods.

Background Acute respiratory failure (ARF) is associated with high ICU mortality. Early prediction of individual ICU outcome is helpful for personalizing management strategies to improve survival. However, individual prediction requires the consideration of a number of risk factors simultaneously, which may be challenging for the human brain. In this study, we explore if machine learning can predict individual ICU outcome based on early clinical and echocardiographic information. Methods Early clinical and the first echocardiographic data (features) from COVID-19 patients with ARF from two previous studies were combined. The importances of a collection of features (risk factors) were ranked and individual ICU outcome predictions based on these features were made using machine learning (XGBoost) algorithm. Machine learning prediction accuracy metrics were reported and were also compared to clinicians’ predictions on the same dataset. Results While age, PaO2/FiO2 (PF) ratio and MAP ranked the top three in the feature importance list, echocardiographic features (LVEF, RVEDA/LVEDA ratio and LVEDV) also contributed significantly to ICU mortality prediction but to a lesser degree. The relationships between each feature with ICU mortality risk were consistent with early studies but not in simple linear relationships. The performance of machine learning prediction of individual ICU outcome was reasonable with accuracy = 0.71 (ROC AUC = 0.76). While the specificity was high (93%), the sensitivity was poor (21%). Interestingly, the prediction performance was similar to clinicians’ predictions (sensitivity = 30%, specificity = 90%, accuracy = 0.69). Conclusions In patients with ARF from COVID, machine learning (XGBoost) shows promise in predicting individual ICU outcomes using a combination of early clinical and echocardiographic information. The prediction was a complex process and needed to take all the risk factors into consideration – a process which is similar to actual clinical practice.

The last specific international European recommendations regarding the management of cardiogenic shock (CS) regardless of the etiology were issued over 10years ago. We present herein recommendations for the management of CS in adults, developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system by an expert group of from the French Intensive Care Society [Société de réanimation de langue française (SRLF)] and the French Society of Cardiology [Société française de cardiologie (SFC)], with the participation of the French Society of Anesthesia and Intensive Care [Société française d’anesthésie et de réanimation (SFAR)], and the French Society of Thoracic and Cardiovascular Surgery [Société française de chirurgie thoracique et cardio-vasculaire (SFCTCV)]. The recommendations covered six fields of application: CS teams and expert centers, symptomatic medical management, etiological management, organ support, temporary circulatory support and de-escalation and early post-CS management. Twenty-three “Patient Intervention Comparator Outcome” (PICO) questions were identified, leading to 41 recommendations regarding management of CS in adult patients. Seven recommendations were scored with high level of evidence (Grade 1), 11 with moderate level of evidence (Grade 2) and 17 with low level of evidence (Expert opinion). In 6 cases, the experts were not able to give an answer. All of the recommendations obtained strong agreement from the expert committee. The experts highlight the fact that optimal management of CS requires organization including a structured, multidisciplinary shock team and regional referral network, applying standardized protocols for diagnosis and staging. Early etiological treatment—such as culprit-lesion revascularization or urgent valve intervention—is central to improve outcomes. Hemodynamic support should prioritize norepinephrine as first-line vasopressor and privilege selective inotrope use. Temporary mechanical circulatory support (Impella, VA-ECMO) should be reserved for carefully selected patients following discussion by the expert team.

Biomarkers have been identified to predict, diagnose and prognosticate acute kidney injury (AKI) but existing studies are heterogenous and contradictory. To compare diagnostic performance of AKI biomarkers, evaluate the quality of AKI biomarker studies and to develop standards for reporting studies of diagnostic test accuracy (DTA) of AKI biomarkers. A systematic literature review was conducted to identify studies focusing on the diagnostic performance of AKI biomarkers published before February 2025. Retrieved DTA studies were assessed for methodological quality and completeness using the QUADAS-2 and Standards for Reporting Diagnostic Accuracy (STARD) 2015 checklists. An international 17 member expert panel was convened to agree consensus standards for AKI biomarker studies (STARDaki) via a modified Delphi process. 122 DTA studies for AKI biomarkers were identified, but 15 were insufficiently reported. Of the remaining 107 studies, only 19 reported on diagnosis of AKI within 48 h of sampling. Of these studies, only 16 were considered high-quality based on the QUADAS-2 criteria. The compliance level with the STARD checklist was too low to permit meta-analysis. The expert panel agreed criteria for patient selection, reference standards, and reporting of test–retest reliability to supplement the STARD guidance for AKI biomarker studies. Most studies examining AKI biomarker performance fail to conform to the STARD standards for reporting, leading to poor diagnostic accuracy estimates and reduced clinical applicability and generalizability. An expert panel proposed STARDaki criteria to advance the development and clinical use of AKI biomarkers ( www.stardaki.icu ).

The Sequential Organ Failure Assessment (SOFA) score is central to Sepsis-3 criteria. SOFA-2 updates thresholds and incorporates contemporary organ support practices, but its impact on sepsis identification and outcome prediction remains uncertain. This study aimed to compare the diagnostic yield and prognostic performance of SOFA-2 versus SOFA-1 for sepsis identification in critically ill adults. We conducted a retrospective multicenter cohort study of 11,669 ICU admissions from three tertiary hospitals in China (January 2022-October 2025) and externally validated findings in 29,811 ICU patients from MIMIC-IV. Sepsis was defined by Sepsis-3 using either SOFA-1 or SOFA-2. We evaluated diagnostic agreement, organ dysfunction profiles, and discrimination for ICU mortality. SOFA-2 identified a significantly larger sepsis population than SOFA-1 (49.0

Purpose Air embolism is a fatal complication of central venous catheter (CVC) manipulation. Its delayed occurrence after CVC removal is poorly understood and underrecognized. We conducted a systematic review to identify all delayed air embolism following CVC removal. Material and methods We included case reports or case series that described venous or paradoxical air embolism occurring ≥10 min after CVC removal. Data extracted included patient demographics, catheter characteristics, removal technique, timing of symptoms onset, clinical presentation, diagnostic tools used, management or treatment and outcomes. Results Twenty-eight case reports were identified. Symptoms developed between ten minutes and one hour after removal of CVC in 54% of cases, between one and two hours in 14%, and after more than two hours in 32%. Neurological manifestations occurred in 92% of patients, oxygen desaturation in 90%, and cardiovascular instability in 47%; cardiac arrest was reported in only two cases. In 10 out of the 11 patients in which diagnostic tools were used to identify a cause, a transcutaneous channel was found. Ten patients were investigated for a patent foramen ovale (PFO), and six of them were negative. 18% had permanent neurological impairment and 32% died. Conclusions Delayed air embolism after CVC removal is an uncommon but potentially severe complication associated with substantial morbidity and mortality. Persistent venous-to-atmospheric communication was identified by imaging techniques in >90% of cases. Increased vigilance during and after CVC removal is necessary to improve future clinical practice.

Twenty-five years of septic shock resuscitation trials have progressively transformed the physiological understanding of shock and the way bedside interventions are conceptualized. Early strategies focused on correcting isolated global hemodynamic or metabolic targets through protocolized interventions, whereas more recent approaches increasingly recognize septic shock as a heterogeneous, dynamic, and context-dependent condition requiring individualized physiological assessment. This perspective discusses how hemodynamic resuscitation trials during this quarter of a century have reshaped both the physiological understanding and methodological foundations of early shock management. Initial strategies, exemplified by early goal-directed therapy, aimed to correct global oxygen-derived variables through protocolized interventions designed to optimize oxygen delivery. However, the lack of reproducibility of this approach in subsequent multicenter trials, together with the recognition of the limitations of several other variables as potential resuscitation targets, revealed that septic shock cannot be adequately addressed through rigid algorithms based on isolated endpoints. Subsequent progress incorporated peripheral perfusion assessment, systematic evaluation of fluid responsiveness, critical care echocardiography, and hemodynamic phenotyping. Within this trajectory, ANDROMEDA-SHOCK shifted attention toward capillary refill time as a rapidly responsive clinical perfusion signal, contributing to improve some outcomes, and potentially limiting over-resuscitation. ANDROMEDA-SHOCK-2 further operationalized a personalized strategy based on capillary refill time, sequential phenotyping, reversible hemodynamic tests, and serial reassessment. A quarter of a century of septic shock resuscitation trials reveal a consistent pattern: strategies centered on fixed and isolated physiological targets have repeatedly failed to achieve reproducible improvements in patient-centered outcomes. Recent data support a shift from isolated hemodynamic or metabolic targets, toward a physiology-guided, phenotype-driven resuscitation strategy, in which interventions are applied as reversible tests within short decision cycles and guided by rapidly responsive perfusion signals. Trials such as ANDROMEDA-SHOCK-2 represent important steps in this ongoing transition, but further refinement, validation, and implementation across diverse settings remain necessary.

A recent Delphi consensus highlighted elements for defining refractory septic shock. We assessed whether integrating persistent tissue hypoperfusion with vasopressor dose after protocolized resuscitation improves mortality risk stratification compared with vasopressor dose alone. We performed an exploratory secondary analysis of the ANDROMEDA-SHOCK-2 trial. After 6 h of hemodynamic resuscitation, refractoriness was operationalized as a norepinephrine equivalent dose (NEE) > 0.5 µg/kg/min plus an abnormal capillary refill time (> 3 s) and non-decreasing lactate (two-hypoperfusion criteria). A complementary analysis included NEE > 0.5 µg/kg/min combined with either of the tissue perfusion criteria. The primary outcome was 28-day mortality. Among 1363 patients with complete data, 188 (13.8

OBJECTIVE:This European Society of Intensive Care Medicine (ESICM) guideline provides evidence-based recommendations on the volume of early resuscitation fluid for adult critically ill patients. METHODS:An international panel of experts developed the guideline, focusing on fluid resuscitation volume in adult critically ill patients with circulatory failure. Using the PICO format, questions were formulated, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was applied to assess evidence and formulate recommendations. RESULTS:In adults with sepsis or septic shock, the guideline suggests administering up to 30 ml/kg of intravenous crystalloids in the initial phase, with adjustments based on clinical context and frequent reassessments (very low certainty of evidence). We suggest using an individualized approach in the optimization phase (very low certainty of evidence). No recommendation could be made for or against restrictive or liberal fluid strategies in the optimization phase (moderate certainty of no effect). For hemorrhagic shock, a restrictive fluid strategy is suggested after blunt trauma (moderate certainty) and penetrating trauma (low certainty), with fluid administration for non-traumatic hemorrhagic shock guided by hemodynamic and biochemical parameters (ungraded best practice). For circulatory failure due to left-sided cardiogenic shock, fluid resuscitation as the primary treatment is not recommended. Fluids should be administered cautiously for cardiac tamponade until definitive treatment and guided by surrogate markers of right heart congestion in acute pulmonary embolism (ungraded best practice). No recommendation could be made for circulatory failure associated with acute respiratory distress syndrome. CONCLUSIONS:The panel made four conditional recommendations and four ungraded best practice statements. No recommendations were made for two questions. Knowledge gaps were identified, and suggestions for future research were provided.

Sepsis is a syndrome of life-threatening organ dysfunction that results from dysregulated host response to infection, with septic shock defined as persistent hypotension despite fluid resuscitation, a serum lactate > 2 mmol/L and the need for a vasopressor infusion to maintain a mean arterial pressure of at least 65 mmHg. Approximately, 49 million cases of sepsis are recorded worldwide annually, with 11 million sepsis-related deaths, the majority occurring in patients with septic shock. A substantial proportion of survivors suffer from moderate to severe functional limitations including physical, cognitive and psychological disability, exacerbation of pre-existing chronic conditions and a high incidence of re-hospitalisation in the first 12 months after the initial diagnosis. Optimal management of patients with septic shock requires prompt and reliable recognition of patients with sepsis who require additional haemodynamic support. Initially, patients will need judicious intravenous fluids and consideration of the need for vasopressors such as norepinephrine. Administration of appropriate antibiotics and consideration for control of the source of infection are also required. In the optimisation phase, depending on patients’ comorbidities and response to therapy, the balance of fluid therapy, vasopressors and potentially the addition of an inotropic agent will need to be adjusted, based on clinical findings and haemodynamic and biochemical parameters. For those patients who do not respond to initial therapy, more intensive monitoring may be required with consideration of adjunctive therapies such as corticosteroids, vasopressin, angiotensin II or other rescue therapies to achieve cardiovascular stability. Once stability has been achieved, clinicians need to consider strategies to ameliorate the potential long-term effects on survivors, while keeping in mind the perspective and experience of their patients.