INTRODUCTION:Patients often receive propofol for sedation and clevidipine for hypertension in the intensive care unit. Both agents are formulated as a lipid emulsion, which may increase the risk of hypertriglyceridemia and acute pancreatitis with their coadministration. We aimed to determine the incidence of hypertriglyceridemia and acute pancreatitis with concurrent administration of propofol and clevidipine and identify patient risk factors for hypertriglyceridemia. METHODS:This was a multicenter retrospective study of adult patients (≥ 18 years old) receiving concurrent propofol and clevidipine infusions for ≥ 6 h. The primary outcome was the frequency of triglyceride levels greater than 400 mg/dL and acute pancreatitis. The secondary outcome was risk factors associated with hypertriglyceridemia during concurrent propofol and clevidipine infusions until both infusions had been discontinued. Univariable and multivariable logistic regression analyses were used to assess risk factors of hypertriglyceridemia in patients receiving concurrent propofol and clevidipine infusions. RESULTS:Across 1,226 patients, the median duration of infusion overlap was 12.4 [interquartile range (IQR) 8.3, 22.7] hours. The mean age of the cohort was 59.6 [standard deviation (SD) 14.9] years, and 59.4% were male. Assuming those without a triglyceride level drawn did not have hypertriglyceridemia, hypertriglyceridemia after initiation of propofol and clevidipine infusion was found in 7.7% [95% confidence interval (CI) 6.3% to 9.3%] of the entire cohort. Twenty-six patients (2.1%) had a diagnosis of pancreatitis after initiation of lipid infusions, of which 12 cases were possibly infusion-related, and one case was likely infusion-related. After calculating the Naranjo Scale, all 13 cases of pancreatitis were possibly related to propofol or clevidipine infusions. Based on a multivariable logistic regression of those with a triglyceride level available, risk factors for hypertriglyceridemia included pancreatitis within the past 5 years [adjusted odds ratio (aOR) 2.77, 95% CI, 1.23 to 6.23] and statin use (aOR 1.94, 95% CI, 1.13 to 3.34). CONCLUSIONS:In our cohort of patients receiving concurrent propofol and clevidipine, the frequency of hypertriglyceridemia and acute pancreatitis was low. Further comparative studies are warranted to assess the risk of pancreatitis with the addition of clevidipine to propofol.

BackgroundCardiac involvement by extranodal natural killer/T-cell lymphoma (ENKTL) and aggressive NK-cell leukaemia (ANKL) is exceedingly rare and presents with heterogeneous manifestations, often leading to diagnostic uncertainty and delay. We contribute three additional biopsy- or autopsy-proven cases and place them in the context of a literature review of previously reported cases classified according to the 5th edition of the World Health Organization (WHO) Classification of Hematolymphoid Tumors.Case seriesThree men (ages 58–72) presented with diverse cardiac manifestations. A 72-year-old with progressive dyspnoea and cardiogenic shock had cMRI findings interpreted as myocarditis on an infiltrative substrate; endomyocardial biopsy confirmed cardiac infiltration by ENKTL. Despite brentuximab vedotin (BV)-based therapy he died shortly thereafter. A 60-year-old with encephalopathy, biventricular dysfunction, and widespread nodal/multiorgan disease had nodal pathology consistent with EBV-negative ANKL according to the criteria of the 5th edition of the WHO Classification of Hematolymphoid Tumors; he declined chemotherapy and died within six days, with autopsy confirming multiorgan (including myocardial and bone marrow) infiltration. A 58-year-old with prior sinonasal ENKTL treated with four cycles of SMILE developed a new right atrial mass one month later; the mass was diagnosed by cMRI/PET-CT concordance and an extracardiac (EBUS-lung) tissue confirmation of the same recurrence. BV followed by gemcitabine/oxaliplatin failed to control progression and he died approximately one month after cardiac spread. Across cases, CD56 was positive in all, EBER in two, and CD30 was expressed variably.ConclusionsCardiac ENKTL/ANKL is a rapidly fatal entity with protean features. Multimodal imaging aids early recognition and tissue targeting, but definitive diagnosis rests on tissue confirmation. L-asparaginase-based chemotherapy remains the treatment backbone; CD30- and PD-L1-guided agents such as BV, PD-1 blockade, and daratumumab may offer transient control after biomarker-guided selection but lack randomized data in cardiac disease. Across the reported experience, survival after cardiac involvement was uniformly short, typically days to a few months. Our three cases add to this literature by illustrating the diversity of cardiac presentations, the variable CD30 expression relevant to brentuximab vedotin use, and the contribution of multimodal imaging to diagnosis. Findings from our series and the pooled literature are descriptive rather than constituting a formal survival analysis, and underscore the need for earlier diagnosis and prospective investigation.

Blood transfusion is common during pediatric craniosynostosis surgery; however, transfusion volumes and use of cell salvage systems can vary considerably. To support preoperative transfusion planning in patients undergoing craniectomy for craniosynostosis, we developed and internally validated machine learning (ML) models to predict perioperative transfusion risks and transfusion volumes in this patient population. Data from eligible patients ≤36 months of age from the NSQIP® Pediatric dataset were included for modeling. A classifier pipeline was developed to predict probabilities associated with transfusion risk, and a probabilistic/quantile regression pipeline was developed to predict the median transfusion volume (in mL/kg) with interquartile range. Performance of the modeling pipelines was evaluated using nested cross-validation with 5-fold outer loops. In total, 8045 patients were included with 4091 (50.9%) receiving perioperative transfusion. For the classification pipeline, the optimal model configuration was a LightGBM classifier. The modeling pipeline achieved a mean area under the receiver operating characteristic curve (AUC-ROC) of 0.77 (95% confidence interval [CI] 0.75-0.78) and mean Brier score of 0.20 (95% CI 0.19-0.20) across nested cross-validation. For the regression stage, the optimal model configuration was a probabilistic NGBoost regressor. The modeling pipeline achieved an average median absolute error of 6.86 mL/kg (95% CI 6.61-7.11), with a mean IQR coverage of 53% (95% CI 52-53%). These models may support individualized blood product preparation and selective use of cell salvage systems. External validation and further real-world testing are needed prior to the clinical implementation of this tool.

An aging population, with rising healthcare needs, places a high strain on the medical workforce. How the aging of healthcare providers affects patient outcomes has garnered considerable interest; however, comprehensive data synthesis is lacking. Therefore, we sought to assess associations between physician age and outcomes of adults receiving medical or surgical care. This systematic review was prospectively registered on PROSPERO (CRD42024503166). MEDLINE and EMBASE were searched to January 16th, 2024, and supplemented by a hand search. Eligible studies included randomized controlled trials or observational studies enrolling adults (≥ 18 years) that examined associations between surgeon or medical physician age and patient outcomes (i.e., mortality, hospital readmission, complications, length of stay). Given the heterogeneity of data, a meta-analysis was not conducted. Across 17 observational studies (n = 7,311,162), 14 (n = 3,944,944) assessed surgeon age while 3 (n = 3,366,218) examined physician age in medical care. Ten studies were rated as having moderate, six having severe, and one having a critical risk of bias. The threshold for older surgeon age varied from ≥ 45 to ≥ 65 years across surgical studies, while those focusing on medical care utilized a cut-off of ≥ 50 to ≥ 60 years of age. Older surgeon age was generally associated with lower patient mortality; however, there were inconsistent and often insignificant differences in operative mortality. Younger surgeon age was associated with higher complication rates in some studies, with mixed findings on readmission rates and no clear association with hospital length of stay. There was limited data on people receiving medical care, but those treated by younger physicians showed evidence of lower mortality. Findings were mixed for both medical and surgical care, with interpretation limited by variable age cut-off definitions, heterogeneous data reporting, and a disproportionate focus on surgical care. Given the aging workforce, further research is needed to support dialogue and policies on medical workforce planning.

BACKGROUND:Anthracycline use is associated with cardiotoxicity. Dexrazoxane may prevent anthracycline-associated cardiotoxicity, yet its adoption remains inconsistent due to concerns about oncologic interference and myelosuppression. METHODS:A systematic review was conducted following PRISMA guidelines (Prospero: CRD420251039900). Medline, Embase, Central, Web of Science, and Scopus were searched from inception to December 2025. Both randomised and observational studies reporting on the effects of dexrazoxane on risk of clinical heart failure (HF) and left ventricular ejection fraction (LVEF) decline, oncologic outcomes (objective response, overall survival, progression-free survival), and hematologic toxicities (anemia, neutropenia, thrombocytopenia) in adults receiving anthracycline-based chemotherapy were included. Random-effects meta-analyses were performed, stratified by study design. Certainty of evidence was assessed according to GRADE. RESULTS:Sixteen studies (n = 3996) were included. Based on moderate certainty randomised trial evidence, dexrazoxane likely reduces clinical HF (relative risk [RR] 0.23, 95% confidence interval [CI] 0.10-0.51) with no difference in neutropenia (RR 1.04, 95% CI 0.98-1.11). Based on low-certainty randomised trial evidence, dexrazoxane may reduce LVEF decline (RR 0.38, 95% CI 0.26-0.54) with little to no difference in objective response (RR 0.91, 95% CI 0.80-1.04), anemia (RR 1.44, 95% CI 1.19-1.75), and thrombocytopenia (RR 0.89, 95% CI 0.65-1.24). Evidence was uncertain regarding the effect on overall and progression-free survival. CONCLUSIONS:Dexrazoxane was associated with a lower risk of clinical HF and LVEF decline without significant differences in cytopenias or oncologic response. However, the certainty of evidence was limited. Further research in contemporary cardio-oncology should focus on non-breast cancer populations, standardise outcome definitions, and evaluate alternative dosing regimens.

IMPORTANCE: Phenobarbital use in ICU alcohol withdrawal syndrome (AWS) may reflect severe or refractory withdrawal and treatment escalation, making multicenter data important to understand its use within ICU practice and its relationship with clinical outcomes. OBJECTIVES: To evaluate phenobarbital use in real-world ICU AWS as a marker of severe or refractory withdrawal and treatment escalation. We also examined its association with time-to-discharge and safety outcomes compared with nonphenobarbital regimens. DESIGN, SETTING, AND PARTICIPANTS: Multicenter retrospective cohort study using multiple imputation and propensity score matching. Adults with AWS, defined as Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) score greater than or equal to 10, were included if they received a phenobarbital-based or nonphenobarbital-based regimen in ICUs across a large academic health system from June 30, 2017, to July 1, 2024. Postoperative ICU admissions were excluded. MAIN OUTCOMES AND MEASURES: Primary outcomes were time to ICU and hospital discharge alive from treatment initiation. Safety outcomes were hypotension, new intubation, and aspiration within 48 hours. RESULTS: Of 1216 patients, 345 (28.4%) received phenobarbital. Before matching, phenobarbital-treated patients had higher CIWA-Ar, Acute Physiology and Chronic Health Evaluation III, and pre-ICU benzodiazepine exposure, consistent with more severe or refractory withdrawal. In adjusted time-to-discharge models, phenobarbital use was not significantly associated with time to hospital discharge alive (discharge rate ratio [DRR], 0.91; 95% CI, 0.74–1.12; p = 0.370) or ICU discharge alive (DRR, 0.77; 95% CI, 0.59–1.01; p = 0.057). Hypotension and intubation were similar, and aspiration was less frequent with phenobarbital. CONCLUSIONS: In a contemporary ICU cohort, phenobarbital use reflected treatment escalation in patients with more severe or refractory AWS. After adjustment, time to ICU and hospital discharge alive did not differ significantly, hypotension and intubation were similar, and aspiration was less frequent with phenobarbital. Future studies should define optimal timing, dosing, and patient selection.

Central venous access in the prone position has historically been challenging, but recent advancements, particularly following the COVID-19 pandemic, have made this approach increasingly feasible. The internal jugular vein (IJV) is one of the most accessible sites for central venous cannulation in patients in the prone position, especially under ultrasound guidance. In this case report, we sought to describe the feasibility and step-by-step approach of central venous dialysis catheter insertion under ultrasound guidance in a patient with critical illness who was transferred in prone position and required urgent plasmapheresis. A 69-yr-old female patient was transferred with severe hypoxemic respiratory failure (partial pressure of oxygen [PaO2]/ fraction of inspired oxygen [FIO2] ratio, 70), new-onset pancytopenia, hemoptysis, and acute renal failure requiring dialysis catheter insertion. Due to inability to tolerate supine positioning and hemodynamic instability, the procedure was performed prone. For right IJV access, the head was slightly rotated contralaterally, the shoulders elevated with an extra pillow, and the bed placed in 20° Trendelenburg position. Placing a linear ultrasound probe transversely, we visualized the sternocleidomastoid muscle, IJV, and carotid artery. We used a modified anterior approach for needle insertion, targeting the lateral wall of the IJV instead of the anterior wall as done in the traditional anterior approach. Once the vein was punctured, the 15-cm, 12-Fr double-lumen dialysis catheter was inserted using the Seldinger technique. Prone central venous dialysis catheter insertion, using a modified anterior approach, can be a potential option for patients with severe hypoxemia in prone position. This unusual and infrequently described approach to dialysis catheter insertion requires further study to better characterize potential associated complications.

OBJECTIVE:To describe site-level ICU organizational policies and implementation of pain, agitation, and delirium (PAD) best practices before the COVID-19 pandemic, and perceived changes during the pandemic. DESIGN:International site-level questionnaire study. SETTING:Participating sites completed a standardized electronic Case Report Form between January 5, 2022 and March 31, 2023. PATIENTS/CENTERS:Ninety-three ICUs caring for adult patients from 79 hospitals across 27 countries in North America, South America, and Europe. INTERVENTIONS:Each ICU submitted data on site characteristics, staffing, implementation of PAD protocols and assessment tools prepandemic, and perceived changes during the COVID-19 pandemic. Descriptive statistics and multivariable logistic regressions were performed using R. MEASUREMENTS AND MAIN RESULTS:Of 93 ICUs, 63% were university-affiliated, and 59% reported a closed physician staffing model. Most managed mixed patient populations (78%), with a nurse-to-patient ratio for ventilated patients of 1:2 (45%) or 1:1 (39%). Physiotherapists and pharmacists were available in 83% and 68% of ICUs, respectively. Over 75% reported routine use of validated PAD scales, most commonly Richmond Agitation Sedation Scale (86%), Confusion Assessment Method for ICU (59%), and Numeric Rating Scale (44%). Protocols were most available for spontaneous breathing trials (60%) and sedation (58%), followed by delirium (53%), mobilization (47%), and pain (46%). University affiliation and 1:1 nurse staffing was associated with reported use of delirium or mobilization protocols. The presence of a weaning protocol was associated with higher odds of daily sedation interruption (adjusted odds ratio [aOR] 3.80; 95% CI, 1.43-10.89; p = 0.009), and use of sedation protocols (aOR 5.95; 95% CI, 2.29-16.86; p < 0.001). Nearly one-half of ICUs reported drug shortages during the pandemic, and 62% prohibited any visitation. CONCLUSIONS:ICU organizational structures and reported PAD practices vary widely worldwide. Despite international guidelines, many ICUs lack consistent implementation of evidence-based sedation, analgesia, and delirium management strategies.

Introduction Angina with no obstructive coronary artery disease (ANOCA) affects millions and is frequently under-recognised because diagnostic pathways and risk tools predominantly target obstructive coronary artery disease (CAD). This protocol describes shared methods for two machine-learning (ML) studies: (1) differentiating ANOCA from stable angina with obstructive CAD and (2) predicting long-term mortality among patients with ANOCA and obstructive CAD.Methods and analysis We will develop and cross-site validate ML classification models using a multicentre retrospective cohort drawn from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease registry and institutional datasets from the University of Ottawa Heart Institute and the University Health Network. Eligible participants are adults (≥18 years) undergoing initial cardiac catheterisation for chest pain/anginal equivalents since 1995, excluding prior revascularisation, major structural heart disease and predefined non-anginal indications. Outcomes are (1) ANOCA (0% to <50% stenosis) versus obstructive CAD (≥50% stenosis) and (2) 1, 3 and 5-year mortality, modelled separately for ANOCA and obstructive CAD.Model development will use nested cross-validation with stratified k-fold inner-loop tuning and leave-one-site-out cross-validation for repeated external validation. Candidate predictors will be harmonised across sites, filtered for missingness and refined using expert/directed acyclic graph-guided selection plus Boruta and Least Absolute Shrinkage and Selection Operator. Preprocessing includes appropriate encoding, missing-data imputation (multivariate imputation by chained equations) and feature scaling. Algorithms will include elastic-net logistic regression, random forest, LightGBM and multilayer perceptron models; hyperparameters will be optimised via Bayesian optimisation. Performance and threshold tuning will be reported. Explainability and subgroup fairness will be assessed using SHapley Additive exPlanations. Final models will be deployed as a web-based clinical risk calculator.Ethics and dissemination Ethics approval has been obtained from the University of Calgary and the University Health Network (#24-5916). Analyses will use deidentified data in secure environments; only aggregate results will be reported. Findings will be disseminated via peer-reviewed publications, conferences and a web-based calculator.

While the use of transesophageal echocardiography (TEE) or pulmonary artery catheters (PAC) has been studied in coronary artery bypass grafting (CABG), outcomes associated with their concurrent use remain understudied. Therefore, we sought to investigate the association between intraoperative TEE, with or without PAC, and patient outcomes following isolated CABG. This population-based study included adults (≥ 18 years old) undergoing isolated CABG from 2009 to 2019 across 11 Ontario centers using administrative databases. The primary outcome was a composite of 30-day mortality and major complications. Multivariable regression with general estimating equations was performed, adjusting for patient, surgical, and hospital factors. Subgroup analyses by surgical urgency and left ventricular ejection fraction (LVEF), and a weighted propensity score sensitivity analysis were done. Among 70,065 patients undergoing CABG, 45.5

Objectives To evaluate the feasibility of off-label transcatheter aortic valve replacement in a 29-year-old man with severe aortic regurgitation (AR) who was not a surgical candidate because of systemic vasculitis. Key Steps The right radial artery was unsuitable because of small caliber and spasm, and the right common iliac artery was occluded, necessitating femoral access with serial dilation. The device was positioned under angiography and deployed during rapid pacing, with subsequent hypotension requiring resuscitation. Postprocedure, hemodynamics improved (mean gradient 3 mm Hg, no regurgitation). Arteriography revealed a left common iliac artery dissection, which was stented. Three-month follow-up confirmed appropriate valve positioning/function. Potential Pitfalls In pure AR, lack of annular/leaflet calcification—especially in younger patients—can impair anchoring. Vasculitis further complicates sizing/deployment and can limit access. Rapid pacing in poorly functioning ventricles carries a risk for cardiac arrest. Long-term durability of transcatheter aortic valve replacement in young patients remains uncertain, and its use for native AR in the United States remains off-label.

We sought to conduct a scoping review to summarize the existing literature on environmental sustainability in critical care medicine, methods for measuring intensive care unit (ICU)-related environmental impact, and interventions to improve ICU environmental sustainability. We conducted a systematic search of four databases to identify studies published before October 2024 pertaining to environmental sustainability and assessment of the carbon footprint of ICUs and manually screened selected journals. The combined search strategy identified 1,967 potentially eligible articles. We conducted a full-text review of 149 articles, of which 99 met eligibility criteria. Articles were categorized into five domains: waste management (n = 31), carbon footprint (n = 20), sustainable medication practices (n = 9), energy delivery/consumption (n = 4), and other (n = 39), with four studies classified into two themes owing to overlap in content. Daily material waste in the ICU ranged from 4.9 to 15.2 kg per patient per day. Most studies reported poor waste sorting practices, and several studies reported reductions in waste generation with multicomponent interventions. Three carbon-footprint-themed studies calculated the carbon footprint of ICUs either through life-cycle assessments or material flow analysis. Eleven studies quantified carbon emission reductions using either prospective or theoretical stewardship interventions related to equipment, medications, or ICU care processes. In this scoping review, we found a rapidly expanding yet fragmented body of evidence on ICU environmental sustainability. Important gaps exist in evidence to guide clinicians on practical bedside strategies and understanding how to implement them to drive meaningful, sustainable change.

BACKGROUND:Anesthesiologists are often tasked with overseeing sedation in non-surgical settings. We aim to determine whether adding adjuvant sedatives to propofol affects the recovery times and complication rates after endoscopy. METHODS:We conducted a retrospective cohort study of adults (≥18) who received propofol while undergoing esophagogastroduodenoscopy (EGD) and/or colonoscopy (COL) at a large academic institution over a four-year period. Patients receiving propofol alone were compared against patients receiving propofol in combination with midazolam, fentanyl, ketamine, or dexmedetomidine. The primary outcome was PACU length of stay, adjusted for age, sex, and ASA Score. Secondary outcomes included incidence of PACU postoperative nausea and vomiting, hypoxemia (SpO2 < 90%), bradycardia (HR < 60 bpm), and escalation of care (hospital admission), reported in adjusted odds ratios and their 95% confidence intervals. RESULTS:Across the study period, 28,532 cases were included. Colonoscopies performed under propofol+fentanyl sedation were associated with significantly longer PACU LOS compared to propofol alone. Adjusted mean PACU LOS was significantly longer in patients receiving adjuvant fentanyl, compared to propofol alone (p < 0.01) and propofol + dexmedetomidine (p < 0.01). Patients receiving propofol alone exhibited a 9.4% incidence of bradycardia, 16.0% hypoxia, 0.89% PONV, and 0.40% hospitalization. Adjuvant fentanyl use was associated with higher odds of hypoxia across all procedure types (p < 0.05). Adjuvant dexmedetomidine was associated with higher rates of bradycardia, but lower rates of hypoxia, PONV, and hospitalization (p < 0.05). CONCLUSIONS:With the exception of fentanyl, combining propofol with other sedatives was not associated with longer recovery times. The incidence of complications differed significantly with the use of adjuvant fentanyl or dexmedetomidine.