Background/Objectives: Emergency surgical patients are at increased risk of acute postoperative delirium. Processed EEG monitoring, such as entropy indices and burst suppression ratio (BSR), may optimize anesthetic dosing, yet their role in non-elective surgery remains underexplored. This retrospective cohort study aimed to examine whether entropy monitoring and intraoperative burst suppression are associated with the incidence of early postoperative delirium during the first 72 h after emergency surgery. Methods: Adult patients undergoing emergency surgery between March 2022 and March 2024 were classified into two groups based on anesthesia records: the entropy-monitored group (EG) and the standard care group without processed EEG (SG). Demographic, intraoperative, and cognitive data (NEECHAM scores during the first 72 h) were extracted from institutional perioperative records. The primary outcome was postoperative delirium (NEECHAM ≤ 24), with secondary analyses examining anesthetic exposure, burst suppression, and intraoperative hemodynamics. Results: Entropy-monitored patients received lower sevoflurane and fentanyl doses and exhibited improved hemodynamic stability, including fewer hypotensive episodes and lower norepinephrine requirements. Early postoperative cognitive dysfunction (NEECHAM ≤ 24) was more frequent among patients with intraoperative burst suppression, with BSR > 15% or suppression duration > 6 min strongly associated with cognitive decline within the first 72 h. Conclusions: In this retrospective cohort, entropy-guided anesthesia was associated with more precise anesthetic titration and more stable hemodynamic parameters. Burst suppression characteristics may serve as indicators of neurocognitive vulnerability rather than solely reflecting direct effects of anesthetic dosing. These results support the use of processed EEG monitoring in emergency surgery, though prospective studies are needed to confirm these findings.

Nutritional support in critically ill patients has been acknowledged as a pillar of ICU care, playing a pivotal role in preserving muscle mass, supporting immune function, and promoting recovery during and after critical illness. Providing effective nutritional support requires adapting it to the patient’s diagnosis, unique characteristics, and metabolic state to minimize the risks of overfeeding or underfeeding while mitigating muscle loss. This level of care requires a comprehensive nutritional assessment and the establishment of a nutrition-focused protocol. Regular, consistent and detailed nutritional evaluation can influence both therapeutic decisions and clinical interventions, thus ensuring that the specific needs of critically ill patients are met from the acute phase through their entire recovery process. Bioelectrical impedance analysis (BIA) is increasingly recognized as a valuable tool for enhancing nutritional care in critically ill patients. By delivering precise, real-time insights into key aspects of body composition, BIA is thought to provide clinicians with a more comprehensive understanding of the complex physiological changes that occur during critical illness. This narrative review highlights the potential of BIA in offering these precise assessments, facilitating the development of more accurate and personalized nutritional strategies for critically ill patients. If BIA can reliably assess dynamic shifts in hydration and tissue integrity, it holds the promise of further advancing individualized care and optimizing clinical outcomes in this vulnerable population.

Background: Bupropion, an atypical antidepressant and smoking cessation aid, is known for its potential to cause seizures, cardiotoxicity and neurotoxicity in overdose scenarios. However, overdoses may present variably, and muscular and renal complications, such as rhabdomyolysis and acute kidney injury (AKI), can emerge in unexpected ways. Previous reports have shown that severe overdoses can lead to a spectrum of complications, but the precise mechanisms linking bupropion overdose with rhabdomyolysis remain poorly understood. Clinical presentation: This paper presents the management of a severe rhabdomyolysis case following deliberate ingestion of 4 g of immediate-release bupropion. The report highlights the unexpected presentation of bupropion overdose, including a lack of typical neurotoxic or muscular symptoms, and the subsequent involvement of multiple factors in the decision to initiate early renal replacement therapy, despite the absence of overt acute kidney injury (AKI). Conclusions: This case underscores the importance of individualized patient assessment and the challenges of managing rare and complex drug overdoses. Early intervention with renal replacement therapy, despite the absence of acute kidney injury, may be justified in cases of significant rhabdomyolysis and potential renal complications. Clinicians should maintain a high degree of suspicion for complications like rhabdomyolysis in overdose scenarios and consider early renal support in patients at risk of renal failure, even in the absence of overt kidney injury. The findings also point to the need for a more nuanced approach to diagnosing and treating bupropion overdose in critically ill patients.

BACKGROUND:In 2018, Romania established national guidelines for patient blood management (PBM), endorsed by the Romanian Society of Anesthesia and Intensive Care (SRATI) and approved by the Ministry of Health. These guidelines emphasize managing anemia, coagulation issues, and the cautious use of allogeneic transfusions to improve patient outcomes. MATERIALS AND METHODS:A national survey was conducted among Romanian anesthesiologists to assess PBM guideline adoption. It included 38 questions addressing PBM strategies, resources, transfusion practices, and barriers to implementation. The survey was distributed via email to the SRATI database. RESULTS:Out of 512 professionals who opened the survey, 74% had adopted some PBM measures, and 97% recognized PBM's efficacy in improving outcomes. However, only 33% of anesthesiologists worked in hospitals with formal PBM groups, and 39% had attended PBM-related educational events. Preoperative anemia management was inconsistent, with only 33.5% routinely treating anemia. Access to diagnostic and therapeutic tools was limited; transferrin saturation testing was available in 27% of cases, and erythropoietin was used in 24%. Despite these limitations, 72% of respondents treated anemia with intravenous iron.The main challenges to implementation included insufficient time for pre-surgical assessments, lack of standardized procedures, and difficulties in surgeon-anesthetist collaboration. DISCUSSION:The survey highlights the need for systemic improvements in PBM adoption. Recommendations include enhancing organizational structures, standardizing protocols, and improving interdisciplinary collaboration to boost PBM implementation in Romania. While progress has been made, a national program with dedicated funding and auditing could facilitate widespread PBM integration into clinical practice.

Trace elements are essential for several physiological processes. To date, various data have suggested that inadequate levels of trace elements may be involved in the pathogenesis of different chronic diseases, including immune-mediated ones, or may develop during their course. Systemic sclerosis (SSc) is a complex autoimmune multisystemic disease, primarily characterized by microvascular dysregulation, the widespread activation of the immune system and tissue fibrosis. According to the latest reports regarding the pathogenesis of SSc, the main pathophysiological processes—inflammation, vasculopathy and fibrosis—may include various trace element derangements. The present literature review aims to update the available data regarding iron, zinc, copper and selenium status in SSc as well as to underline the possible implications of these trace elements in the complexity of the pathogenic process of the disease. We observe that the status of trace elements in SSc plays a crucial role in numerous pathogenic processes, emphasizing the necessity for proper monitoring and supplementation. The reported data are heterogenous and scarce, and future studies are needed in order to draw clearer conclusions about their complete spectrum.

Coagulopathy and traumatic brain injury (TBI) are complexly intertwined. In isolated TBI, coagulopathy may contribute to hemorrhagic lesion development, progression, or recurrence, as it may lead to a particular pattern of coagulopathy called TBI-induced coagulopathy (TBI-IC). We performed a retrospective and descriptive evaluation of 63 patients admitted to the Emergency Clinical Hospital Bucharest with the diagnosis of moderate/severe brain injury. In addition to demographic data, all included patients had a complete paraclinical evaluation that included rotational thromboelastometric (ROTEM) blood-clot analysis. The platelet component (PLTEM) and the endotheliopathy activation and stress index score (EASIX) were calculated. These parameters were presented comparatively according to survival at 30 days and helped define the two study groups: survivors and non-survivors at 30 days. The contribution of platelets to clot strength is derived from maximum clot elasticity (MCE) and maximum clot firmness (MCF). MCE is defined as (MCF × 100)/(100 − MCF), and PLTEM is defined as EXTEM MCE—FIBTEM MCE. EASIX is a novel biomarker recently studied in TBI patients, calculated according to the following formula: lactate dehydrogenase (U/L) × creatinine (mg/dL)/platelets (109 cells/L). Regarding the demographic data, there were no significant differences between the survivors and non-survivors. All ROTEM parameters related to clot amplitude (A5, A10, A20, MCF in EXTEM and FIBTEM channels) were higher in the group of patients who survived. Also, PLTEM was decreased in the group of deceased patients (89.71 ± 22.86 vs. 132.3 ± 16.56 p < 0.0001). The cut-off point determined with the ROC curve is 114.10, with a sensitivity of 94.74% and a specificity of 93.18%, for the detection of the negative prognosis (death at 30 days). The EASIX score was significantly higher in the patients who survived the traumatic event, with a median difference value of 1.15 (p < 0.0001). The ROC analysis of this biomarker highlights a cut-off point of 2.12, with a sensitivity of 88.64% and a specificity of 94.74% (AUC = 0.95, p < 0.0001), for the prediction of mortality. The comparative analysis of the two studied markers was performed using the Cox proportional hazard ratio and highlighted the greater influence that PLTEM has on survival time (b value = −0.05, p < 0.0001) compared to EASIX (b value = 0.49, p = 0.0026). The present retrospective study indicates the potential of the TBI-IC reflecting parameters PLTEM and EASIX as markers of mortality prognosis. Larger prospective studies are needed to confirm their combined prognostic value and use in decision-making and reduction in the burden of disease by adequate allocation of resources in a personalized and timely manner.

Micronutrient (MN) status alterations (both depletion and deficiency) are associated with several complications and worse outcomes in critically ill patients. On the other side of the spectrum, improving MN status has been shown to be a potential co-adjuvant therapy. This review aims to collect existing data to better guide research in the critical care setting. This narrative review was conducted by the European Society of Intensive Care Medicine Feeding, Rehabilitation, Endocrinology, and Metabolism MN group. The primary objective was to identify studies focusing on individual MNs in critically ill patients, selecting the MNs that appear to be most relevant and most frequently investigated in the last decade: A, B1, B2, B3, B6, folate, C, D, E, copper, iron, selenium, zinc, and carnitine. Given the limited number of interventional studies for most MNs, observational studies were included. For each selected MN, the review summarizes the main form and functions, special needs and risk factors, optimal treatment strategies, pharmacological dosing, and clinical implications all specific to critically ill patients. A rigorous rebalancing of research strategies and priorities is needed to improve clinical practice. An important finding is that high-dose monotherapy of MNs is not recommended. Basal daily needs must be provided, with higher doses in diseases with known higher needs, and identified deficiencies treated. Finally, the review provides a list of ongoing trials on MNs in critically ill patients and identifies a priority list of future research topics.

Postoperative neurocognitive impairments following surgery are a growing concern, especially in the elderly population, since it is associated with a significantly increased risk of morbi-mortality in the postoperative period. Among them, delirium or the early postoperative cognitive decline is associated with a further risk of prolonged cognitive dysfunction and it may quicken long-term cognitive impairment or postoperative cognitive dysfunction (POCD). The current knowledge regarding preventive strategies for delirium is not focused anymore only on pharmacological and behavioral management strategies in the postoperative period, but also supports the preoperative cognitive training programs. Since preoperative cognitive evaluation and proactive interventions to optimize surgical patient outcomes are rather impossible in the emergency setting, what are the appropriate preventive strategies that can be implemented in day-to-day practice? In this review, we try to highlight the most recent experimental and clinical strategies, and outline the most relevant recommendations for clinicial practicioners based on the available data.

Background/Objectives: The complexity of trauma-induced coagulopathy (TIC) is a result of the unique interactions between the patient, trauma, and resuscitation-related causes. The main objective of trauma resuscitation is to create the optimal milieu for both the development of immediate reparatory mechanisms and the prevention of further secondary injuries. Endotheliopathy represents one of the hallmarks of trauma-induced coagulopathy, and comprises endothelial dysfunction, abnormal coagulation, and inflammation, all of which arise after severe trauma and hemorrhagic shock. Methods: We retrospectively and descriptively evaluated 217 patients admitted to the Bucharest Clinical Emergency Hospital who met the Berlin criteria for the diagnosis of multiple trauma. Patients with high suspicion of auto-heparinization were identified according to the dynamic clinical and para-clinical evolution and subsequently tested using rotational thromboelastometry (ROTEM). The ratio between the clot formation time (CT) was used, obtained on the two channels of interest (INTEM/HEPTEM). Results: Among the 217 patients with a mean age of 43.43 ± 15.45 years and a mean injury severity score (ISS) of 36.98 ± 1.875, 42 patients had a reasonable clinical and para-clinical suspicion of auto-heparinization, which was later confirmed by the INTEM/HEPTEM clotting time ratio in 28 cases (12.9% from the entire study population). A multiple linear regression analysis highlighted that serum lactate (estimated 0.02, p = 0.0098) and noradrenaline requirement (estimated 0.03, p = 0.0053) influenced the CT (INTEM/HEPTEM) ratio. Conclusions: There is a subset of multiple trauma patients in which the CT (INTEM/HEPTEM) ratio was influenced only by serum lactate levels and patients’ need for vasopressor use, reinforcing the relationship between shock, hypoperfusion, and clotting derangements. This emphasizes the unique response that each patient has to trauma.

PURPOSE OF REVIEW:Thiamine is a crucial component in cellular energy metabolism, serving as a cofactor for multiple enzymatic processes and also having a role in regulating neuronal and neuromuscular transmission. Also it exerts antioxidant proprieties. The objective of this review is to consolidate and assess the most recent research concerning the consequences of insufficient thiamine levels for critically ill patients and to examine thiamine-related interventions.RECENT FINDINGS:Recent studies have unveiled a noteworthy association between thiamine deficiency and unfavorable consequences, such as heightened morbidity and fatality rates. The aforementioned deficiency exhibits a significant presence in medical situations such as starvation and alcohol use disorder, but also in patients during critical illness. Thiamine deficiency can have significant metabolic implications resulting in compromised energy generation and organ dysfunction, warranting prompt recognition and management.SUMMARY:Thiamine deficiency may not be recognized in critical care. Timely identification and management are imperative to mitigate adverse outcomes and improve patient prognosis. Thiamine may offer benefits for specific patient groups at higher risk of deficiency. Future studies should focus to establish optimal dosing, timing, and monitoring strategies on understanding the pathophysiological changes associated with thiamine deficiency in ICU patients and clarify its role in improving clinical outcomes.

Background: Blunt thoracic trauma possesses unique physiopathological traits due to the complex interaction of immune and coagulation systems in the lung tissue. Hemogram-based ratios such as neutrophil-to-lymphocyte (NLR), platelet-to-lymphocyte (PLR), neutrophil-to-lymphocyte × platelet (NLPR) ratios have been studied as proxies for immune dysregulation and survival in trauma. We hypothesized that blunt thoracic trauma patients exhibit distinct patterns of coagulation and inflammation abnormalities identifiable by the use of readily available hemogram-derived markers. Methods: The present study represents a retrospective observational analysis that included 86 patients with blunt thoracic trauma from a single high-volume level one trauma center. The primary outcome was mortality prediction in blunt thoracic trauma patients using these derived biomarkers. Secondary outcomes included phenotypes of the immune response and coagulopathy and the prediction of non-fatal adverse events. Results: A U-shaped distribution of mortality was found, with high rates of early deaths in patients with an NLPR value of <3.1 and high rates of late deaths in patients with NLPR > 9.5. A subgroup of blunt thoracic trauma patients expressing moderate inflammation and inflammation-induced hypercoagulation objectified as NLPR between 3.1 and 9.5 may have a survival benefit (p < 0.0001). The NLPR cut-off for predicting early deaths and the need for massive transfusion was 3.1 (sensitivity = 80.00% and specificity = 71.05%). Conclusions: These findings suggest that blunt thoracic trauma patients exhibit distinct phenotypes of the immune response and coagulopathy from the early stages. A controlled, balanced interaction of immune, coagulation, and fibrinolytic systems might effectively achieve tissue repair and increase survival in thoracic trauma patients and should be subject to further research.

Considering the increasing prevalence of obesity among the critically ill patient, mechanical ventilation of this type of patients has almost become a daily practice. However, no consensus regarding mechanical ventilation for obese patients has recently been published. Considering the particular pathophysiological features of respiratory system in obese patients, the risk of ventilator induced lung injury (VILI) is highly elevated. This narrative review aims to present the constrains related to mechanical ventilation in obese patients, as well as the features that predispose them to VILI. Moreover, the effects every determinant incriminated in VILI were described with application on the pathophysiological features of obese patients. Increased emphasis was placed on the newly concept of ergotrauma as one of the main determinants of VILI. This is one of the first reviews dedicated to the effects of mechanical power and ergotrauma on mechanically ventilated patients with obesity. Moreover, increased attention was given to the impact of biotrauma related to VILI, considering that the new concept of “pre-conditioning cloud” related to obesity has recently emerged.

The administration of intravenous lipid emulsion (ILE) is a proven antidote used to reverse local anesthetic-related systemic toxicity. Although the capacity of ILE to generate blood tissue partitioning of lipophilic drugs has been previously demonstrated, a clear recommendation for its use as an antidote for other lipophilic drugs is still under debate. Venlafaxine (an antidepressant acting as a serotonin–norepinephrine reuptake inhibitor (SNRI)) and quetiapine (a second-generation atypical antipsychotic) are widely used in the treatment of psychotic disorders. Both are lipophilic drugs known to induce cardiotoxicity and central nervous depression. We report the case of a 33-year-old man with a medical history of schizoaffective disorder who was admitted to the emergency department (ED) after having been found unconscious due to a voluntary ingestion of 12 g of quetiapine and 4.5 g of venlafaxine. Initial assessment revealed a cardiorespiratory stable patient but unresponsive with a GCS of 4 (M2 E1 V1). In the ED, he was intubated, and gastric lavage was performed. Immediately after the admission to the intensive care unit (ICU), his condition quickly deteriorated, developing cardiovascular collapse refractory to crystalloids and vasopressor infusion. Junctional bradycardia occurred, followed by spontaneous conversion to sinus rhythm. Subsequently, frequent ventricular extrasystoles, as well as patterns of bigeminy, trigeminy, and even episodes of non-sustained ventricular tachycardia, occurred. Additionally, generalized tonic–clonic seizures were observed. Alongside supportive therapy, antiarrhythmic and anticonvulsant therapy, intravenous lipid emulsion bolus, and continuous infusion were administered. His condition progressively improved over the following hours, and 24 h later, he was tapered off the vasopressor. On day 2, the patient repeated the cardiovascular collapse and a second dose of ILE was administered. Over the next few days, the patient’s clinical condition improved, and he was successfully weaned off ventilator and vasopressor support. ILE has the potential to become a form of rescue therapy in cases of severe lipophilic drug poisoning and should be considered a viable treatment for severe cardiovascular instability that is refractory to supportive therapy.

Ankylosing spondylitis is one of the global top health burdens and patients affected by it frequently require surgery related to disease progression, such as orthopedic surgery. These patients may prove difficult to manage from an anesthetic standpoint, regardless of the anesthetic technique employed, mainly given the potential for difficult airway access and related comorbidities. We present the case of a 52-year-old male posted for urgent cemented total hip arthroplasty with associated bilateral pulmonary fibrosis and an anticipated difficult airway in whom regional anesthesia was performed with satisfactory results, with a favorable intraoperative and postoperative course. The literature review explores the anesthetic techniques employed when a tailored approach is required in managing patients with ankylosing spondylitis.

Bacterial and viral sepsis induce alterations of all hematological parameters and procalcitonin is used as a biomarker of infection and disease severity. Our aim was to study the hematological patterns associated with pulmonary sepsis triggered by bacteria and Severe Acute Respiratory Syndrome–Coronavirus–type-2 (SARS-CoV-2) and to identify the discriminants between them. We performed a retrospective, observational study including 124 patients with bacterial sepsis and 138 patients with viral sepsis. Discriminative ability of hematological parameters and procalcitonin between sepsis types was tested using receiver operating characteristic (ROC) analysis. Sensitivity (Sn%), specificity (Sp%), positive and negative likelihood ratios were calculated for the identified cut-off values. Patients with bacterial sepsis were older than patients with viral sepsis (p < 0.001), with no differences regarding gender. Subsequently to ROC analysis, procalcitonin had excellent discriminative ability for bacterial sepsis diagnosis with an area under the curve (AUC) of 0.92 (cut-off value of >1.49 ng/mL; Sn = 76.6%, Sp = 94.2%), followed by RDW% with an AUC = 0.87 (cut-off value >14.8%; Sn = 80.7%, Sp = 85.5%). Leukocytes, monocytes and neutrophils had good discriminative ability with AUCs between 0.76–0.78 (p < 0.001), while other hematological parameters had fair or no discriminative ability. Lastly, procalcitonin value was strongly correlated with disease severity in both types of sepsis (p < 0.001). Procalcitonin and RDW% had the best discriminative ability between bacterial and viral sepsis, followed by leukocytes, monocytes and neutrophils. Procalcitonin is a marker of disease severity regardless of sepsis type.

Rationale: Data on initial metabolic changes and their impact on body composition in critically ill septic patients are lacking despite increased monitoring of the measured resting energy expenditure (mREE). Ultrasound techniques are reliable tools to assess muscle mass in ICU setting, considering that these are not influenced by rapid fluid shifts.