Lung-protective ventilation is a cornerstone of modern mechanical ventilation, yet real-world adherence to lung-protective targets remains suboptimal. While previous studies have established the physiological benefits of low tidal volume and driving pressure, clinical implementation is hindered by limited monitoring granularity and lack of real-time actionable feedback. This trial aims to evaluate whether a real-time, cloud-based algorithmic feedback platform can improve lung-protective ventilation delivery and contribute to better clinical outcomes in mechanically ventilated patients with ARDS. This multicentre, parallel-group, open-label randomised controlled trial will enrol 208 adult mechanically ventilated ICU patients with ARDS from nine adult ICUs across tertiary academic hospitals and regional referral centres in multiple provinces and municipalities in mainland China. Participants will be randomly assigned in blocks to receive either standard monitoring (Control group) or real-time respiratory mechanics feedback through a cloud-based platform (Intervention group). The intervention group will receive real-time alerts for lasting 72 h and ventilator reports every 24 h, integrating tidal volume, plateau pressure, driving pressure, mechanical power, and detected patient–ventilator asynchrony events. The primary outcome is the lung-protective ventilation achievement rate, defined as compliance with VT < 8 mL/kg predicted body weight, driving pressure < 15 cmH₂O, plateau pressure < 30 cmH₂O, and mechanical power < 17 J/min during the first 72 h after randomisation. Secondary outcomes include ventilator-free days at day 28, ICU length of stay, ventilator-associated complications, inflammatory biomarkers, clinician satisfaction, and predefined safety outcomes, including severe hypoxemia, severe hypercapnia/acidemia, barotrauma, and hemodynamic instability temporally associated with ventilator adjustments. This study is, to our knowledge, among the first multicentre randomised controlled trials to evaluate a real-time algorithmic feedback platform designed to enhance lung-protective ventilation. The intervention is designed to provide continuous bedside feedback on ventilation mechanics and may enable more timely and standardised clinical adjustments, with the potential to facilitate lung-protective ventilation delivery. Triaiontl registration ClinicalTrials.gov Identifier NCT07307066 (Registration Date: 2025/12/02).

L’intubation trachéale au bloc opératoire est un geste quotidien, généralement simple, mais pouvant entraîner des complications graves en cas de difficulté ou de tentatives répétées. L’identification préopératoire des voies aériennes difficiles reste imparfaite, et une proportion significative d’intubations compliquées survient de manière imprévue, y compris en chirurgie programmée. Au cours des dernières décennies, le vidéolaryngoscope s’est imposé comme l’évolution technologique majeure de la gestion des voies aériennes. En dissociant l’axe de vision de l’axe de progression de la sonde, il améliore la visualisation glottique et optimise les conditions de la première tentative d’intubation. Les données issues de méta-analyses, d’essais randomisés récents et d’études d’implémentation en conditions réelles montrent que, comparée à la laryngoscopie directe, la vidéolaryngoscopie augmente le taux de succès au premier passage et réduit le nombre de tentatives nécessaires, avec un impact variable mais globalement favorable sur les complications. Son bénéfice apparaît particulièrement marqué dans les situations à haut risque (induction en séquence rapide, obésité, grossesse, etc.). Au-delà de l’efficacité technique, le vidéolaryngoscope constitue un outil central de formation et de supervision, favorisant la communication d’équipe et l’intégration des facteurs humains. Les recommandations internationales récentes soutiennent une utilisation plus large du vidéolaryngoscope, intégrée dans une stratégie institutionnelle associant organisation des pratiques et réflexion médico-économique. Cette mise au point propose une analyse narrative de la littérature et discute les bénéfices, les limites, les modalités pratiques et les enjeux organisationnels et économiques du vidéolaryngoscope au bloc opératoire, ainsi que sa place croissante comme dispositif de première intention en anesthésie.

BACKGROUND:Inflammatory phenotypes of acute respiratory distress syndrome (ARDS) predict outcomes and can respond differently to treatment strategies. We aimed to establish whether these phenotypes differ in respiratory mechanics and in response to lung-protective ventilation strategies. METHODS:In this retrospective cohort study, data from two cohorts were harmonised. Patients with moderate-to-severe ARDS with oesophageal manometry data from the EPVent-2 trial (14 hospitals across the USA and Canada) and a retrospective cohort at Beth Israel Deaconess Medical Center (Boston, MA, USA) were merged and lung mechanics were compared. Patients had to be aged 18 years or older, have moderate to severe ARDS, and be monitored with oesophageal manometry. To analyse the primary outcome of 60-day mortality after ARDS onset, we used multivariable Cox models for each inflammatory phenotype to study the associations between measures of lung-protective ventilation (driving pressure, transpulmonary driving pressure, and end-expiratory transpulmonary pressure) and 60-day mortality in all patients who had complete data for all variables. FINDINGS:Between Jan 1, 2008, and Jan 31, 2024, 5778 patients were assessed for eligibility (200 in the EPVent-2 cohort and 5578 in the BIDMC cohort). Of these patients, 890 were included in this study cohort (200 from the EPVent-2 trial and 690 from the retrospective cohort), of whom 424 (48%) had the hyperinflammatory phenotype and 466 (52%) had the hypoinflammatory phenotype. 232 (55%) patients in the hyperinflammatory group and 136 (29%) patients in the hypoinflammatory group died within 60 days (p<0·0001). The effects on 60-day mortality were more pronounced among patients with the hypoinflammatory phenotype than the hyperinflammatory phenotype for high respiratory system driving pressure (≥15 cm H2O; adjusted hazard ratio 2·01 [95% CI 1·39-2·91] vs 1·46 [1·11-1·94]; pinteraction=0·033) and high transpulmonary driving pressure (≥12 cm H2O; 2·36 [1·64-3·39] vs 1·18 [0·84-1·60]; pinteraction=0·0010). In addition, having an end-expiratory transpulmonary pressure within plus or minus 2 cm H2O was protective among the hypoinflammatory (0·66 [0·46-0·93]) but not the hyperinflammatory phenotype (0·97 [0·73-1·27]). Excess mortality among the hyperinflammatory phenotype was mediated by extrapulmonary organ failure (proportion mediated 46% [+17 to +79]) but not respiratory failure (0% [-3 to +4]). INTERPRETATION:Our findings suggested that in ARDS, the association between lung-protective mechanical ventilation and 60-day mortality is greater in patients with the hypoinflammatory phenotype than the hyperinflammatory phenotype, therefore patients with hypoinflammatory ARDS could be an important target population for enrichment of future clinical trials. However, our findings do not support different ventilation strategies based on phenotype. Although both phenotypes present with similar lung mechanics, extrapulmonary organ failure is the key driver of excess mortality among patients with the hyperinflammatory phenotype. FUNDING:Société Française d'Anesthésie-Réanimation, the University Hospital of Montpellier, Philippe Foundation, the Department of Anesthesia at Beth Israel Deaconess Medical Center, and Jeffrey and Judy Buzen.

Acute Respiratory Distress Syndrome (ARDS) encompasses heterogenous subphenotypes. We assessed whether morphological subphenotypes of Acute Pancreatitis-related ARDS have differential responses to prone position and positive end-expiratory pressure (PEEP). We analyzed a retrospective cohort of all consecutive critically ill adults with Acute Pancreatitis-related ARDS and early CT-scan admitted to ICU from 2003 to 2023. ARDS was classified according to CT-scan as “Focal ARDS” or “Non-Focal ARDS.” The primary outcome was 90-day mortality. Treatment effects for prone position and high PEEP were assessed. Adjusted Hazard Ratios (aHR) were calculated with a multivariate Cox analysis. Machine-learning models were developed with XGBoost and explained with SHAP. Among the 5,865 patients screened, 151 Acute Pancreatitis-related ARDS were included in the analysis. Eighty-one patients (54

Postoperative patients have been underrepresented in randomized controlled trials of acute respiratory distress syndrome (ARDS). Whether postoperative ARDS differs from medical ARDS in its clinical trajectory, outcomes, and prognostic determinants remains unclear. We aimed to compare postoperative and medical ARDS with respect to early trajectory, mortality, and risk factors for mortality. We conducted a retrospective analysis of prospectively collected data in a tertiary ICU from 2003 to 2023. All consecutive intubated adults fulfilling the ARDS New Global Definition were included. ARDS cases were labeled as postoperative when onset occurred within 15 days after surgery. The primary outcome was 90-day mortality, assessed with multivariable Cox analysis. Early ARDS trajectories were assessed at day 3. Multivariable Cox analyses were used to identify factors independently associated with mortality. Among 1,077 intubated ARDS patients, 455(42

Artificial intelligence (AI) predictive models demonstrate potential for transforming clinical decision-making across medicine. However, conventional randomized controlled trials (RCTs), the gold standard for evaluating medical interventions, are ill-suited for clinical AI tools due to their static design, lengthy timelines, and inability to accommodate algorithms that evolve and adapt to changing clinical contexts. In this narrative review, we outline the limitations of traditional evaluation frameworks and propose a paradigm shift toward adaptive, iterative, and context-specific assessment methodologies. Evaluating clinical AI in practice requires three interdependent but epistemologically distinct activities: performance monitoring, which tracks the technical characteristics of the deployed model (calibration, discrimination, data drift, alert burden, fairness, workflow fidelity); clinical impact monitoring, which observationally and prospectively tracks whether the initial clinical benefit appears sustained over time; and scientific evidence generation, which produces causal estimates of deployment effects on patient outcomes through pragmatic, adaptive trial designs and causal inference techniques. We propose a predictive-AI-specific framework that links performance monitoring, clinical impact monitoring, evidence generation, causal estimands, and governance of model updates into one coherent decision pathway for clinicians and trialists. We present a governance-driven escalation protocol specifying when monitoring signals should trigger formal evidence generation, a decision pathway mapping signal types (performance or clinical impact) to trial design classifications, and a guide to causal inference methods for clinical AI trials. Drawing from adaptive platform and pragmatic trial designs, we recommend continuous monitoring approaches that prioritize patient-centered outcomes, health equity, and workflow integration over narrow performance metrics, and provide actionable steps to design a clinical AI trial. Successful implementation requires clinician engagement, transparency, and ongoing education regarding AI capabilities and limitations. Within this new evaluation paradigm, predictive AI can progress from a promising technology to reliable clinical tools that improve patient outcomes, support clinical decision-making, and uphold ethical standards in routine practice.

Introduction Mental health problems among undergraduate medical students are a major global public health concern that emerge early during training and are shaped by demanding educational environments, emotional stressors and organisational pressures. Although research has expanded rapidly, the literature remains fragmented across themes, regions and methods. This scoping review aims to map the global quantitative literature on medical students' mental health and identify gaps in scope, geography, methodology and equity.Methods and analysis This scoping review will be conducted in accordance with the Joanna Briggs Institute methodological guidance and reported in accordance with PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. We will include quantitative studies assessing mental health among undergraduate medical students. MEDLINE (Ovid), Web of Science (Clarivate), the Cochrane Library (Wiley) and PsycINFO (Ovid) will be searched without date or language restrictions using a keyword-based search strategy. Two reviewers will independently screen titles, abstracts and full texts and extract data using a standardised form. Data will include publication year, country, study design, sample size, mental health measures, thematic domains and patterns of collaboration. Mental health domains will be classified using an a priori thematic framework encompassing psychological symptoms and distress, psychological resources, academic environment, social support and physical health and lifestyle factors. Equity-related variables (sex, gender identity, sexual orientation, race/ethnicity, socioeconomic status) will be operationalised based on analytical use. Results will be synthesised descriptively using tables and visualisations.Ethics and dissemination Ethical approval is not required. Findings will be disseminated through publication and presentations. The dataset and code will be openly available on publication.Trial registration details Protocol registration will be made available online via the Open Science Framework (doi:10.17605/OSF.IO/2EHNU).

Two randomized trials (BICAR-ICU and BICAR-ICU2) evaluated intravenous sodium bicarbonate therapy in patients with severe metabolic acidemia but yielded inconclusive results. We performed an individual patient data meta-analysis to assess its effects on 90-day mortality and renal replacement therapy (RRT) use, and search for heterogeneity of treatment effects across prespecified subgroups. We performed an individual patient data meta-analysis of the BICAR-ICU and BICAR-ICU2 trials, including adults with severe metabolic acidemia (pH ≤ 7.20). Patients were randomized to receive intravenous sodium bicarbonate titrated to a pH ≥ 7.30 or no sodium bicarbonate. The primary outcome was 90-day mortality. Secondary outcomes included RRT initiation and dialysis-free days. Prespecified subgroup analyses explored treatment-effect heterogeneity by acidemia depth (pH ≤ 7.10 vs. > 7.10), severe acute kidney injury (AKI) status, and serum lactate (< 2mmol/L vs. ≥2mmol/L). A total of 1,016 patients was included (509 sodium bicarbonate, 507 control). Sodium bicarbonate therapy did not significantly reduce 90-day mortality compared to control (58.3

Background Acute liver injury (ALI) is a life-threatening condition that may require liver transplantation (LT). For over three decades, the King’s College Hospital (KCH) and Clichy-Villejuif (CV) criteria have guided LT decisions, but their relevance in the modern intensive care unit (ICU) era remains uncertain. This study aimed to assess the “real-life” incidence of LT among ICU patients with ALI fulfilling these criteria. We retrospectively analysed prospectively collected data from 2000 to 2025 in a tertiary ICU with an active LT program. All consecutive adult patients with ALI fulfilling KCH and/or CV criteria without contraindications were included. The primary endpoint was the incidence of LT. Secondary endpoints included ICU and one-year survival, organ support requirements, temporal trends and transplant-free survival according to criteria fulfilment. Results Among 396 patients with ALI, 118 fulfilled KCH and/or CV criteria without contraindications for LT. The incidence of LT was 34% (40 out of 118). ICU and one-year survival did not significantly differ between transplanted and not transplanted patients (88% vs. 92% and 85% vs. 81%, respectively). Transplanted patients had more severe liver dysfunction, reflected by higher MELD scores driven by higher values of bilirubin and INR. They were more likely to have auto-immune hepatitis (23% vs. 1%, p < 0.01), and less likely to have acetaminophen-induced (25% vs. 46%, p = 0.03) or ischaemic ALI (2% vs. 26%, p < 0.01). Encephalopathy progression was more frequent in transplanted patients. The delay between ICU admission and LT significantly increased over the study period. Among not transplanted patients, one-year transplant-free survival exceeded 80% overall and remained high across all KCH/CV fulfilment patterns. Conclusion In our cohort, only one-third of ALI patients fulfilling emergency LT criteria underwent transplantation. These findings suggest that historical KCH and CV criteria have limited ability to identify patients with poor prognosis without LT in the context of modern intensive care.

OBJECTIVES:To assess the impact of Molecular Adsorbent Recirculating System (MARS) therapy on total plasma piperacillin concentrations in critically ill patients with acute liver failure or acute-on-chronic liver failure. DESIGN:Retrospective, single-center observational cohort study. SETTING:University ICU. PATIENTS:Consecutive adult patients treated with MARS therapy and piperacillin-tazobactam between March 2023 and June 2025. INTERVENTIONS:MARS therapy was delivered as 8-hour sessions for up to three consecutive days. Piperacillin-tazobactam was administered by continuous infusion following a loading dose. MEASUREMENTS AND MAIN RESULTS:Venous blood samples were collected immediately before and after each MARS session. Total piperacillin concentrations were quantified using ultrahigh-performance liquid chromatography. The primary endpoint was the relative reduction in plasma piperacillin concentration induced by MARS therapy. Thirty patients (121 piperacillin measurements across 77 sessions) were analyzed. Seventy-three percent had cirrhosis (median Model for End-Stage Liver Disease Score 31 [23-38]). The mean relative reduction in piperacillin concentration per session was 34% (± 7.9%; p < 0.05). In univariable mixed-effects analysis, MARS session (β -47.49 mg/L; p < 0.001) and creatinine clearance (β -0.37 mg/L per mL/min; p < 0.001) were associated with lower concentrations. In multivariable modeling, higher creatinine clearance was independently associated with greater intra-session piperacillin loss ( p < 0.001), whereas higher bilirubin levels were associated with reduced drug loss ( p = 0.01). Overall, 31.6% of post-session concentrations were less than 80 mg/L, and 38% of patients had at least one concentration outside the predefined target range. CONCLUSIONS:MARS therapy was associated with a one-third reduction in total plasma piperacillin concentrations per session. These findings support systematic therapeutic drug monitoring and individualized antibiotic dose adjustment during MARS therapy.

Acute mesenteric ischemia (AMI) is associated with low survival rates. It is recommended to start early a full dose of anticoagulation therapy in patients with AMI, regardless of etiology, surgical or procedural perspective, or coagulation status. However, there are no international studies addressing the impact of timing and dose of anticoagulation therapy on outcome in AMI patients hospitalized in the intensive care unit (ICU). This international study combined data from 33 ICU centers in 19 countries. The primary outcome was 30-day survival. Secondary outcomes assessed duration of mechanical ventilation, ICU length of stay, occurrence of hemorrhagic complications and 90-day survival. We also identified independent risk factors for 30-day survival. Among the 370 analyzed patients, 183 received early full-dose anticoagulation therapy and 187 did not. The 30-day survival was 53.5

La ventilation mécanique est un élément clé de la prise en charge anesthésique et réanimatoire, visant à assurer des échanges gazeux adéquats lorsque la ventilation spontanée est compromise. Les recherches en physiologie de la ventilation soulignent des stratégies protectrices pour le poumon et le diaphragme. La recherche continue à avancer dans la définition plus précise de la ventilation protectrice pulmonaire. Les concepts récents de pression motrice et de puissance mécanique aident à évaluer la contrainte imposée au poumon pour adapter les réglages. Des outils de monitorage de précision sont évalués pour guider la ventilation protectrice et améliorer le rapport recrutement/surdistension, comme la manométrie œsophagienne et la tomographie à impédance électrique. La prise en compte d’une ventilation protectrice s’étend désormais au maintien de la fonction diaphragmatique. L’atrophie musculaire respiratoire, favorisée par une forte sédation et une ventilation contrôlée prolongée, complique le sevrage. L’ajustement précoce à un mode assisté et la personnalisation sont des pistes prometteuses pour préserver la contractilité diaphragmatique. La neurostimulation diaphragmatique, encore peu évaluée, apparaît comme une alternative potentielle pour générer un travail musculaire bénéfique tout en assurant une ventilation efficace même en ventilation contrôlée. Enfin, certaines populations comme les patients atteint d’obésité ou les femmes présentent des particularités physiologiques nécessitant une adaptation de la ventilation. L’avenir de la ventilation mécanique réside ainsi dans une approche de plus en plus personnalisée, alliant mesures physiologiques et l’optimisation simultanée de la protection pulmonaire et diaphragmatique. Cette personnalisation guidera les futures pratiques en anesthésie, réanimation et médecine périopératoire.

Delirium is frequent in critically ill patients and is associated with increased mortality. Discrepancies were found in the results of recent randomized controlled trials (RCTs) regarding the effect of melatonin to prevent delirium onset in critically ill patients. We searched MEDLINE, Embase, and Web of Science from inception to 5 July 2025 for RCTs evaluating melatonin in critically ill patients. The primary outcome was the incidence of delirium. The main secondary outcome was mortality. We generated pooled risk ratios (RR). To base our conclusions on the highest quality of evidence, our primary analysis was based only on the trials with low to moderate risk of bias for each outcome. A secondary analysis was conducted, including all the trials. The study was registered with PROSPERO (CRD420251041661). Our primary analysis was based on six RCTs with 2209 patients and did not show any difference in the incidence of delirium attributable to the treatment with melatonin (RR 0.89, [95

Postoperative pulmonary complications (PPC) affect over 10% of surgical patients, especially after abdominal, thoracic, or cardiac surgery. Understanding PPC's pathophysiology and risk factors provides an effective framework for prevention strategies. Significant alterations of the respiratory function occur in all patients undergoing major surgery, especially if the surgical site is close to the diaphragm. The main changes observed are a reduction in lung volumes, with the development of restrictive patterns of respiratory mechanics, atelectasis, and diaphragmatic dysfunction. Hypoxemia often develops in patients after major surgery and may lead to acute respiratory failure (ARF). Postoperative ARF may require reintubation, which has been associated with mortality and healthcare-associated pneumonia. The Peri-Operative Positive Pressure (P.O.P) Ventilation concept includes multiple interventions ranging from positive pressure pre-oxygenation to intraoperative lung protective ventilation and tailored postoperative noninvasive respiratory support. Such strategies aim to mitigate the onset of ARF and prevent a reduction in lung volumes. Despite the inevitability of respiratory function alterations after surgery and anesthesia, perioperative interventions can significantly reduce complications. Positive pressure pre-oxygenation enhances the safety of the intubation procedure and prevents the decrease in lung volumes. Intraoperative lung-protective ventilation associating low to moderate tidal volumes based on predicted body weight, positive end-expiratory pressure, and careful recruitment maneuvers have been effective in decreasing PPC. The respective roles of noninvasive ventilation (NIV) and high-flow nasal oxygenation (HFNO) in preventing PPC remain to be clarified. Their efficacy in preventing the onset of ARF may depend on the ability to identify high-risk patients and tailor interventions accordingly. Current evidence supports curative NIV as the gold standard to treat postoperative ARF in comparison to conventional oxygen therapy or HFNO. As the understanding of the complex interplay between major surgery and respiratory function evolves, so must approaches to tailoring perioperative ventilation support.

BACKGROUND:Long-term controlled mechanical ventilation in the intensive care unit induces ventilator-induced diaphragm dysfunction (VIDD). The transition from controlled mechanical ventilation to assisted mechanical ventilation is a challenge that requires clinicians to balance overassistance and underassistance. While the effects of overassistance on the diaphragm are well known, the authors aimed to assess the impact of underassistance on diaphragm function and structure in a piglet model with preexisting VIDD (after long-term controlled mechanical ventilation) or without VIDD (short-term controlled mechanical ventilation). METHODS:Twenty-two Large White female piglets were anesthetized, ventilated, and separated into two groups: a VIDD group (n = 10) with long-term 72-h controlled mechanical ventilation, and a no-VIDD group (n = 12) with short-term 2-h controlled mechanical ventilation. After sedation reduction at the end of the controlled mechanical ventilation period, each piglet was switched to underassisted ventilation for 2 h. Diaphragm function (supramaximal diaphragm pressure-generating capacity assessed by negative tracheal pressure after transvenous phrenic nerve stimulation) and diaphragm structure (mini-invasive in vivo biopsies) were assessed before and after underassisted ventilation. RESULTS:In the VIDD group, supramaximal diaphragm pressure-generating capacity decreased by 22% from (mean ± SD) 69.9 ± 12.7 to 54.9 ± 19.7 cm H 2 O ( P = 0.04) after 72 h of controlled mechanical ventilation evidencing VIDD, then dropped by a further 29% from 54.9 ± 19.7 to 38.9 ± 15.5 cm H 2 O ( P < 0.01) after 2 h of underassisted ventilation. Diaphragm pressure-generating capacity remains stable from 55.3 ± 22.7 to 58.2 ± 24 cm H 2 O ( P = 0.24) in the no-VIDD group. Diaphragm structure showed that sarcomeric injuries increase from 13 ± 10% to 24 ± 19% ( P < 0.01) and lipid droplets decrease from 14 ± 8% to 11 ± 6% ( P = 0.03) of the total micrograph area after 2 h of underassisted ventilation in the VIDD group. Sarcomeric injuries and lipid droplets accounted, respectively, for 17 ± 16% and 2 ± 3% of the total micrograph area after underassisted ventilation in the no-VIDD group. CONCLUSIONS:In this porcine model, a short 2-h exposure of underassisted ventilation induces impairment of diaphragm function with damage to the diaphragm structure in intensive care unit condition with preexisting VIDD.