Stress-induced hyperglycemia is a frequent metabolic response to polytrauma. To date, studies primarily analyzed its association with mortality; however, its effect on functional outcomes remain unclear. This study investigated the association between sustained hyperglycemia across metabolic phases and functional outcomes in polytraumatized ICU patients. This retrospective single-center observational study included 176 adult ICU polytrauma patients admitted to a German level 1 university trauma center (2013–2023). Blood ​glucose was quantified using admission values, time-weighted averages, variability and time-unified hyperglycemic rate (TUHyperR; cutoffs 140/160/180 mg/dL) across the early “ebb” (≤ 48 h) and later “flow” (> 48 h) metabolic phases. Primary endpoint was functional outcome using Glasgow outcome scale (GOS; unfavorable GOS ≤ 3). Temporal trends were analyzed using mixed-effects models, and associations with outcomes were assessed using multivariable logistic regression. Patients with unfavorable outcomes (39.2

Abstract Acute kidney injury (AKI) is a frequent and clinically relevant complication after cardiac surgery. Early prediction remains challenging because serum creatinine is a delayed and insensitive marker of renal dysfunction. Glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) are incretin hormones with established metabolic functions and emerging roles in cardiovascular, renal, and critical illness–related pathophysiology, and their perioperative association with AKI remains incompletely characterised. In this prospective single-centre observational study, 107 adults undergoing elective cardiac surgery were enrolled. Serum GLP-1 and GIP were measured at four time points (preoperatively, immediately postoperatively, and on postoperative days 1 and 4). AKI was defined according to KDIGO criteria. Subgroup analyses excluded patients with chronic kidney disease (CKD). Postoperative AKI occurred in 21 patients (19.6%), predominantly KDIGO stage 1. These patients had longer ICU stays (5 [2–12] vs. 3 [1–10] days; p < 0.001), higher SAPS II scores (35 [28–39] vs. 29 [25–33]; p = 0.027), and higher SOFA scores on postoperative days 1 and 4 (both p < 0.05). Preoperative GLP-1 levels were significantly elevated in patients who developed AKI (38.3 [30–52] vs. 27.4 [16.7–48.9] pmol/L; p = 0.04), whereas baseline creatinine and GIP did not differ. The association between GLP-1 and AKI remained significant after excluding patients with CKD. Preoperative endogenous GLP-1 levels were associated with postoperative AKI and were elevated earlier in the perioperative course compared with serum creatinine, particularly in patients without CKD. These findings suggest that GLP-1 may reflect early renal stress or vulnerability and warrant further investigation in larger cohorts.

Lung-protective ventilation (LPV) reduces mortality in ARDS, but adherence remains incomplete and women and shorter patients disproportionately receive tidal volumes above predicted-body-weight (PBW)-based targets. The relative associations of recorded sex and body height with this disparity remain uncertain. Retrospective single-centre cohort study (January 2013 to December 2023, RWTH Aachen University Hospital surgical ICU). Adults (≥ 18 years) with Berlin-definition ARDS receiving mechanical ventilation for ≥ 72 h were included. Patient-level adherence to lung-protective targets was described, and repeated-measure PBW-normalised tidal volume and mechanical power were analysed with linear mixed-effects models containing a patient-level random intercept and fixed effects for recorded sex, centred recorded height, age, BMI, SAPS II, SOFA, ARDS aetiology, linear relative ICU day and the lowest same-day PaO₂/FiO₂ ratio. Among 798 adults (263 women [33.0

Hypoxemia in mechanically ventilated ICU patients can evolve rapidly, and early detection is critical for timely intervention. We developed and internally validated a machine–learning clinical decision support system to predict near–term oxygenation deterioration using retrospective data from a single university hospital ICU (March 2020–September 2022). The cohort included 3676 adults who received $\unicode{x2A7E}$ 24 h of cumulative invasive mechanical ventilation; analyses were performed in 3267 adults with complete oxygenation data (65.84% male; 62.4% aged ${\lt}$ 70 years, 24.6% 70–79, 13.0% $\unicode{x2A7E}$ 80). Because ARDS onset could not be adjudicated without chest imaging, the primary endpoint was rapid oxygenation loss between two non–overlapping 24 h windows separated by 48 h, defined as either (i) an absolute decline in mean daily PaO _2 /FiO _2 ${\gt}$ 100 mmHg when baseline ${\gt}$ 450 mmHg or ${\gt}$ 60 mmHg when baseline ${\gt}$ 350 mmHg, or (ii) crossing thresholds from ${\gt}$ 250 to ${\lt}$ 200 mmHg or from ${\gt}$ 150 to ${\lt}$ 100 mmHg. Models were trained with 5–fold hyperparameter tuning and evaluated on a stratified, 10% patient/ICU–visit hold–out test set (event rate 11.2%). The gradient–boosted tree model achieved ROC AUC = 0.89 and PR AUC = 0.52, outperforming a baseline logistic regression model. Probabilities were calibrated on the validation split (Brier = 0.095; expected calibration error = 0.0004). At a 0.10 risk threshold, sensitivity 0.776, specificity 0.844, PPV 0.387, NPV 0.967, and alert rate 22.6%; at 0.20, sensitivity 0.658, specificity 0.911, PPV 0.484, NPV 0.955, and alert rate 15.3% were achieved. By modeling oxygenation dynamics rather than static cutoffs, the system identifies patients at risk for clinically significant hypoxemia up to 72 h in advance. These results support the feasibility of forecasting oxygenation loss in ventilated ICU patients; external validation and prospective evaluation are needed to assess generalizability and clinical impact.

Sepsis-associated acute kidney injury (SA-AKI) remains a frequent and life-threatening complication of sepsis, yet its pathophysiology is still not fully understood, owing to the complex interplay of immune, vascular and parenchymal responses. Closing this knowledge gap is essential for developing urgently needed targeted therapies. Although bulk and single-cell transcriptomics, as well as proteomic approaches, have advanced our understanding of the molecular mechanisms involved in SA-AKI, they lack the spatial context required to fully interpret tissue heterogeneity and microenvironmental changes. The integration of high-resolution spatial transcriptomics with single-cell RNA sequencing and other multi-omics approaches offers a novel lens through which to dissect the cellular and molecular architecture of septic kidneys. In SA-AKI, discrete inflammatory, vascular and tubular niches can cause substantial functional impairment even though global histological changes may be much milder. Integrative spatial transcriptomics localizes pathological signalling and how it is transmitted across immune, endothelial and epithelial cells. By resolving niche-specific crosstalk, these approaches might highlight druggable pathways and lead to the identification of clinical biomarker candidates. These insights, in turn, facilitate the identification of mechanistic endotypes that align more closely with prognosis than with conventional staging. Importantly, translation into clinical trials will require standardized endotype definitions, endotype validation and standardized sampling strategies, as well as scalable analytical pipelines to enable endotype identification at the bedside.

Traumatic brain injury (TBI) is a major cause of trauma-related deaths. Systemic glucose and lactate levels reflect secondary metabolic derangements over time; however, most prognostic models rely on admission values. This study compared static and longitudinal indices of glucose, lactate, and their ratio in relation to ICU mortality. This retrospective single-center study analyzed 479 non-diabetic adult patients with TBI admitted to a German university ICU (2013–2023). After 1:2 severity-balanced, outcome-stratified propensity score matching, 229 patients (150 survivors, 79 non-survivors) were included. Indices comprised admission values, means, clearance, time-weighted averages, variability, and dysglycemic burden. Outcome was ICU mortality, assessed using regression, mixed-effects modeling, and ROC analysis. Longitudinal indices showed stronger associations. Time-weighted average lactate was the best independent predictor (OR 14.70, 95

Intensive Bemühungen und interdisziplinäre Zusammenarbeit haben die Mortalität mehrfach schwer verletzter Patienten deutlich gesenkt. Qualitativ hochwertige Leitlinienempfehlungen, die die prähospitale Phase, das Schockraummanagement und die erste operative Phase behandeln, werden regelmäßig aktualisiert. Der vorliegende Beitrag referiert den Teil einer neuen Leitlinie auf S3-Niveau, der die Behandlung polytraumatisierter und intensivmedizinisch betreuter Patienten nach der ersten operativen Phase fokussiert. Diese Patienten benötigen besondere Aufmerksamkeit u. a. hinsichtlich Monitoring, Schmerztherapie, Beatmungsstrategie, Ernährung etc. und müssen regelhaft noch der definitiven chirurgischen ihrer Verletzungen zugeführt werden. Der Beitrag fasst die aktuelle Literatur zusammen und gibt Empfehlungen hinsichtlich der frühen definitiven Versorgung polytraumatisierter Patienten, v. a. mit Blick auf ihren besten Zeitpunkt.

The treatment of polytraumatized patients is challenging. Intensive efforts and interdisciplinary teamwork have improved survival rates of severely injured patients over the last decades. High quality guideline recommendations focusing on the prehospital setting, emergency room management and also the initial surgical phase have been published and are frequently updated. The current manuscript is part of new guidelines on an S3 level that focuses on treatment of polytraumatized patients who were transferred to the intensive care unit after initial emergency treatment. These patients have special needs, especially with respect to monitoring, pain management, ventilation strategy, nutrition etc. and most often require definitive surgical stabilization of injuries to the thorax, abdomen, pelvis and extremities. This article summarizes the current literature and gives recommendations with respect to early definitive treatment of patients with multiple trauma and particularly with a view to the best possible timing of the definitive treatment.

Introduction: Minimally invasive direct coronary artery bypass grafting (MIDCAB) offers a less traumatic alternative to conventional median sternotomy. The benefits of avoiding sternotomy align with the goals of enhanced recovery after surgery (ERAS). While early extubation benefits have been demonstrated in conventional CABG, evidence on extubation in the operating room remains scarce. We present a single‐center experience with immediate extubation outside of a structured ERAS concept. Methods: Patients undergoing MIDCAB via a left anterolateral thoracotomy with unilateral ventilation between August 2022 and March 2024 were retrospectively analyzed. Patients who were extubated in the operating room (extubation in tabula, EIT) were compared to those who were extubated in the intensive care unit (ICU) (control, CTRL). The primary outcome was a transfer to general ward within 24 h after admission to ICU. Secondary outcomes aimed to assess safety endpoints, including the rate of reintubation, major adverse cardiac and cerebrovascular events, and length of stays. Results: A total of n = 79 patients were included. After propensity score matching, the cohorts consisted of n = 20 (CTRL) and n = 35 (EIT) patients, who had a median age of 68 years (IQR: 63–75), were 83.6% male, and showed comparable baseline characteristics. The majority of patients (92.7%) underwent single arterial bypass grafting. Fifteen patients (27.3%) met the primary endpoint with no significant difference between the two cohorts (CTRL 20.0%, EIT 31.4%, p = 0.531). Three patients in the EIT cohort required reintubation due to revision surgery ( n = 2) and cardiopulmonary resuscitation ( n = 1) due to thrombotic ischemia. The median stay in ICU was 23 h (IQR: 18–28), the total length of hospital stay 6d (IQR: 5–8) respectively. Conclusion: EIT after MIDCAB is safe and feasible. However, on its own, it does not affect subsequent transfers and should therefore be only considered as the first step toward a comprehensive ERAS approach.

Proenkephalin A 119–159 (PENK) is a promising functional kidney biomarker, evaluated in various clinical settings. In critical care medicine, early diagnosis of acute kidney injury (AKI) is crucial; however, to date, the diagnosis and the assessment of kidney function is still based on serum creatinine (sCr) and urine output, both associated with several limitations. Between November 2020 and March 2022, we implemented PENK in our daily practice on our intensive care units (ICU). PENK, sCr, AKI stage, and the start and duration of renal replacement therapy (RRT) were documented. Almost 18,000 PENK measurements from 4169 patients were analyzed, and the glomerular filtration rate (GFR) was estimated with the new PENK-GFR formula. PENK outperformed sCR in the kidney function assessment and sCR trajectory over time. Moreover, PENK predicted the use of RRT and thus showed its usefulness in critical care daily practice.

The question of whether crystalloid or colloid fluid yields better outcomes in the treatment of polytrauma patients has recently garnered significant interest. This systematic review aims to comprehensively compare the effects of crystalloid versus colloid fluid resuscitation on treatment outcomes in polytrauma patients. We searched PubMed, Cochrane Central Register of Controlled Trials and Web of Science to identify completed and ongoing studies from inception of each database to August 9, 2022. We included systematic reviews and randomized controlled trials (RCTs) comparing crystalloid versus colloid fluid resuscitation on treatment outcomes in polytrauma patients admitted to the intensive care unit (ICU). We included one RCT with a total of 2,857 adult participants (mean age 63 years in the colloids and crystalloids group, 62.2

BACKGROUND AND RESEARCH QUESTION:Adequate staffing, especially with physicians and emergency nursing staff, is essential for high-quality emergency care. The aim of this study was to compare the current staffing situation in German emergency departments with recommended standards. METHODS:A questionnaire was developed based on the minimum standards of the German Interdisciplinary Association for Intensive and Emergency Medicine and the German Society for Interdisciplinary Emergency and Acute Medicine. Both the actual staffing and the perceived adequacy were assessed. The anonymous online survey was sent via the joint emergency department registry to the management of 1008 emergency departments. RESULTS:Between 1 June and 31 July 2023, 176 emergency departments (18% response rate) participated. Annual patient numbers ranged from 17,610 to 37,251 depending on the level of care. Qualified nursing and medical leadership was mostly present (about 90%, medical leadership in level 1: 68%). Continuous physician presence was 76%, specialist presence 50%. Specialists with additional emergency medicine training were available in level 1 (one physician) and in levels 2 and 3 (two physicians each). Only 50% of hospitals offered the full 24-month training period. A nurse-to-patient ratio of 1:1200 was met in 40-63% of departments; triage nurses met requirements in 54% of cases. CONCLUSION:The survey shows that significant staffing deficits persist in German emergency departments at all levels of care-especially regarding the presence and qualifications of physicians, nursing staff, social services, and case management. At the same time, a positive trend in equipment, infrastructure, and staff qualifications is evident.

Das deutsche Gesundheitssystem steht den Herausforderungen einer alternden Bevölkerung mit einer zunehmenden Anzahl chronisch und multimorbid Erkrankter, z. T. mit Pflegebedürftigkeit und –angesichts des anhaltenden Personalmangels – zeitgleich eines begrenzten Versorgungsangebots gegenüber. Das aus Mitteln des Europäischen Fonds für regionale Entwicklung (EFRE NRW) geförderte Projekt Telemedizin@NRW adressiert diese Herausforderungen und verfolgt eine ganzheitliche Konzeptbeschreibung – samt technischer Überprüfung – für die Versorgung chronisch erkrankter, multimorbider Patientinnen und Patienten, in dessen Mittelpunkt das indikationsübergreifende Telemonitoring steht. Indikationsübergreifend, da sich Krankheiten (Multimorbidität, Komorbidität) teils gegenseitig bedingen und verstärken; daher muss auch deren Behandlung ganzheitlich, organ- und krankheitsbildübergreifend gedacht werden. Im Projekt wurden dabei die Anwendungsfälle Kardiologie, Dermatologie und Pneumologie betrachtet. Auf Basis der vorliegenden Projekterkenntnisse soll die Frage „Ist Telemonitoring indikationsübergreifend technisch realisierbar?“ beantwortet werden. Die im Projekt eingesetzte und aufgrund der Bedarfe weiterentwickelte Telemedizin-Plattform konnte die technischen Anforderungen erfüllen. Hierdurch wurde aufgezeigt, dass ein indikationsübergreifendes Telemonitoring technisch und prozessual umsetzbar ist. Für die Umsetzung solcher Versorgungsformen müssen sektorenübergreifende Strukturen mit interoperablen Systemen weiterentwickelt werden.

OBJECTIVE:To use digital twins constructed based on data from patients with acute respiratory distress syndrome (ARDS) to calculate all key indices of ventilator-induced lung injury (VILI) during airway pressure release ventilation (APRV), and to compare them with corresponding values obtained during pressure-controlled ventilation (PCV). DESIGN:Digital twins were created by matching a high-fidelity cardiopulmonary simulation model to each patient's data. SETTING:Interdisciplinary Collaboration in Systems Medicine Research Network. SUBJECTS:A dataset consisting of pairs of ventilator settings and arterial blood gases for 98 patients with ARDS receiving PCV. INTERVENTIONS:VILI indices were calculated for each recorded PCV datapoint, and for typical APRV settings in fixed and time-controlled adaptive modes, in the same digital twins. Global optimization algorithms evaluated greater than 4.8 million changes to these settings to identify the lowest values of VILI indices that could be achieved in both modes while preserving adequate gas-exchange. MEASUREMENTS AND MAINS RESULTS:In digital twins, APRV settings of inspiratory pressure equals to 25 cm H 2 O, low-pressure setting equals to 0 cm H 2 O, inspiration time equals to 5 s, and expiration time set to achieve 75% of peak expiratory flow rate (mean 0.5 s), reduced mean mechanical power (MP) by 32% and mean tidal alveolar recruitment/de-recruitment by 34% compared with documented PCV settings, at the cost of moderate hypercapnia (mean PaC O2 58.5 mm Hg, pHa 7.32 vs. Pa CO2 45.6 mm Hg, pHa 7.37). Mean driving pressure, tidal volume, and lung stress/strain were similar in both modes. Computational optimization showed that these settings were close to optimal in terms of minimizing both mean MP and mean levels of tidal recruitment/de-recruitment during APRV. CONCLUSIONS:Using digital twins we found possible lung-protective conditions and beneficial effects of APRV which need further evaluation in randomized clinical trials.

The German healthcare system is facing challenges of an aging population with an increasing number of chronically ill patients with multimorbidity. Some of these are in need of nursing care, but there is a limited supply of care due to continuing shortage of personnel. The project, Telemedizin@NRW, funded by the Europ & auml;ischen Fonds f & uuml;r regionale Entwicklung (EFRE NRW), addresses these challenges and pursues a holistic concept - including a technical review - for the care of chronically ill patients with multimorbidity by focusing on cross-indication telemonitoring. Cross-indication is emphasized because diseases (multimorbidity, comorbidity) are in part mutually dependent and reinforcing. Therefore, their treatment must also be holistically "thought" of across organs and disease patterns. In the project, cases from cardiology, dermatology and pneumology were considered. Based on the available project findings, the technical feasibility of telemonitoring across indications was investigated. The telemedicine platform that was used in the project and then further developed on the basis of additional needs was able to meet the technical requirements. This development demonstrated that cross-indication telemonitoring is technically and procedurally feasible. To implement such forms of care, cross-sector structures with interoperable systems must be further developed.

Medical Nutrition Therapy (MNT) is a key component of treatment in intensive care units (ICU) and plays a crucial role in the prognosis of critically ill patients. An individualized nutrition strategy is essential to meet the specific needs of critically ill patients and to minimize potential complications.Recommendations for MNT differ between the guidelines of the German Society for Nutritional Medicine (DGEM), the European Society for Clinical Nutrition and Metabolism (ESPEN), and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), making its implementation in clinical practice challenging. Therefore, the first part of this article provides a pragmatic summary of the current recommendations for everyday clinical practice. The second part focuses on recent data and how these might influence current paradigms of MNT for critically ill patients, with particular emphasis on phase-appropriate macronutrient delivery and combinations of nutrition with other interventions.

BACKGROUND:Critically ill burn patients face severe metabolic stress, divided into early ebb and late flow phases, causing dysglycemia. While detrimental effects of hyper- and hypoglycemia in burn patients have been reported over the entire stay, its impact during the ebb and flow phases remains unexplored. This study is the first to investigate phase-separated dysglycemia for outcome prediction. METHODS:This retrospective, single-center observational study examined burn ICU patients between 2009 and 2022. Non-severe (ABSI<7) and severe (ABSI≥7) burn patients were investigated separately. Furthermore, the effect of low (<50 %) versus high (≥50 %) dysglycemic rates (<70 or >140 mg/dL) was evaluated within the ebb and flow phases. Dysglycemia was calculated using the time-unified rate, an innovative method representing blood glucose over time. The primary outcome of this study was mortality. RESULTS:This study included 67 non-severe and 101 severe burn patients. During the flow compared to the ebb phase, non-severe burn patients showed increased hyperglycemic rates (>140 mg/dL, p = 0.027) and mean blood glucose levels (p = 0.003), while severe burn patients showed increased glycemic variability (p < 0.001) and hypoglycemic rates (<70 mg/dL, p = 0.003). Non-severe burn patients with high dysglycemic rates showed increased length of ICU stay (ebb: p = 0.029, flow: p = 0.040) and pneumonia incidence (ebb: p = 0.005, flow: p = 0.002) compared to patients with low dysglycemic rates. High dysglycemic rate was associated with higher mortality in severe burn patients (ebb: p = 0.027, flow: p = 0.008). Multivariate logistic regression revealed that hyper- (OR: 1.034, 95 %-CI: [1.001-1.068], p = 0.045) and hypoglycemic rates (OR: 1.744, 95 %-CI: [1.180-2.577], p = 0.005) during the flow, but not the ebb phase, predicted mortality in severe burn patients. CONCLUSIONS:This study suggests that increased dysglycemic rate plays a relevant role in both non-severe and severe burn patients, with a varying impact. Over time, the flow phase was characterized by higher glycemic variability as well as hyper- and hypoglycemic rates, with the latter two predicting mortality in severe burn patients. While larger cohorts are needed to confirm these findings, the data indicate that reducing the dysglycemic rate, particularly during the flow phase, could improve outcomes in critically ill burn patients.