Delirium is a common yet underrecognized neuropsychiatric syndrome in cardiovascular medicine associated with prolonged hospitalization, increased mortality, and long-term cognitive decline. Patients undergoing interventional or surgical cardiovascular procedures-such as transcatheter aortic valve replacement, surgical aortic valve replacement, coronary artery bypass grafting, or percutaneous coronary interventions-may be particularly vulnerable to its development. Delirium incidence varies widely across cardiovascular procedures, influenced by patient characteristics, procedural invasiveness, and diagnostic methodology. Risk factors include advanced age, baseline cognitive impairment, cerebrovascular disease, extended operative times, perioperative complications, and systemic inflammation. Diagnostic tools such as the Confusion Assessment Method (CAM) and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) score are established but underutilized in the diagnosis of delirium. While preventive strategies emphasizing non-pharmacological, multicomponent approaches-such as early mobilization, cognitive stimulation, and sleep hygiene-are supported by strong evidence, preventive use of pharmacologic agents remains controversial. Pharmacologic treatment is reserved for select cases; dexmedetomidine shows benefits in intensive care unit settings, while antipsychotics like quetiapine and risperidone may be used cautiously. Overall, delirium poses a significant clinical challenge in cardiovascular medicine and requires a proactive, interdisciplinary approach. Systematic risk assessment and multimodal preventive strategies should be the standard of care, while pharmacologic treatment should be symptom- and context-specific. Further high-quality studies are needed to inform evidence-based guidelines tailored to cardiovascular populations. The present state-of-the-art review summarizes the current literature on the epidemiology, mechanisms, clinical manifestations, diagnosis, prevention, and treatment of delirium in cardiovascular medicine. By integrating findings and interdisciplinary expert discussions from interventional cardiology, cardiac surgery, and psychiatry, it aims to define the unique vulnerability of this patient population, highlight critical knowledge gaps, and lay the foundation for developing targeted, evidence-based management strategies.

BACKGROUND:The postoperative assessment of the tissue is a major challenge in reconstructive flap surgery. Lactate serves as a key indicator of metabolic dysfunction, providing essential insights into tissue oxygenation and perfusion, cellular stress, and identifying potential pathological conditions. Consequently, continuous monitoring of lactate levels is vital for postoperative tissue analysis in patients undergoing microvascular tissue transfer to prevent serious complications. However, methodologies for the time-resolved sensing of metabolic biomarkers across various body fluids still pose a major challenge and are currently out of reach. MATERIALS AND METHODS:To address the need for time-resolved detection, we developed an innovative portable device relying on droplet-based microfluidics technology for monitoring lactate levels in interstitial fluids (ISFs) in an enzyme-based fluorometric manner. This device was evaluated on individual animal samples and during in vivo trials, with results benchmarked against a standard clinical blood gas analyzer. RESULTS:System demonstrates high accuracy and sensitivity (limit of detection of ca . 2 µM versus 100 µM for the clinical method), coupled with a short response time ( ca. 0.5 minutes) and reagent-saving process (reducing 90% reagent usage in traditional methods). Using a microdialysis probe, we enabled continuous and minimally invasive collection of ISF dialysate. The lactate measurements in ISF closely correlate with those obtained from the blood gas analyzer and exhibited long-term stability, delivering high temporal resolution (0.5 seconds intervals) over an 8-hour animal trial. Comparative analysis revealed that lactate levels in ISF were consistently higher and exhibited a slight lag compared to blood lactate levels. CONCLUSION:This approach demonstrated highly selective, sensitive, and robust detection of lactate in a clinical environment, with a microfluidics-powered instrument. We expect that this strategy can be used in the future as a tool for time-resolved biomarkers monitoring for bedside postoperative care.

To synthesize physiological principles and practical monitoring strategies for perioperative and intensive care hemodynamics, addressing two questions: which variables should be monitored, and what targets should be pursued to optimize outcomes. The review is educational in scope and highlights instrumentation details and clinical applications.Narrative, physiology-anchored review of oxygen delivery, venous return (VR), and regulation of mean arterial pressure (MAP) as a derived target. Reviews for educational purposes are included, with emphasis on instrumentation principles and clinical use cases. Invasive and non-invasive modalities are compared. Evidence from goal-directed therapy (GDT) trials in operating room and intensive care contexts is summarized to link physiology with therapy.(1) adequacy of oxygen delivery cannot be judged from MAP alone; MAP reflects the interaction of cardiac output (CO), systemic vascular resistance (SVR), and right atrial pressure. (2) VR depends on effective circulating volume, venous compliance, and mean systemic filling pressure. (3) Microcirculatory assessment remains limited; macrocirculatory surrogates and biomarkers provide guidance but have constraints. (4) Device outputs labeled identically are not interchangeable; calibration strategy and physiological assumptions are decisive. (5) GDT improves processes and may benefit selected high-risk patients, but large trials show mixed effects on mortality.Effective hemodynamic management requires physiology-based reasoning: identify the limiting factor, then select monitoring tools and therapeutic targets accordingly. MAP must be interpreted with CO, SVR, and RAP. Individualized, dynamic targets and trend-based responses outperform fixed thresholds. Embedding ultrasound skills, fluid-responsiveness testing, and calibrated device interpretation are levers to translate monitoring into safer care.

Extracorporeal membrane oxygenation (ECMO) is an established life-saving therapy for severe acute respiratory distress syndrome and cardiogenic shock, yet it profoundly alters cardiopulmonary physiology and challenges conventional hemodynamic monitoring. Both venovenous (VV) and venoarterial (VA) ECMO modify venous return, ventricular loading conditions, pulmonary vascular resistance, and ventriculo-arterial coupling, leading to complex interactions between native and extracorporeal circulation. As a result, many standard monitoring techniques, particularly indicator-based and pressure-derived methods, lose validity or require careful reinterpretation under ECMO conditions. This review summarizes current evidence on hemodynamic monitoring during VV- and VA-ECMO and critically evaluates commonly used modalities, including echocardiography, invasive arterial pressure monitoring and pulse wave analysis, transpulmonary thermodilution, pulmonary artery catheterization, and microcirculatory monitoring. We highlight configuration-specific pathophysiology, key methodological limitations, and typical sources of misinterpretation for each technique. Particular emphasis is placed on the dissociation between macrocirculatory variables and tissue perfusion, the impact of parallel circulation and flow mixing in VA-ECMO, and the persistence of occult shock despite apparently adequate systemic targets. We propose a physiology-guided, multimodal monitoring framework that integrates pressure, flow, volumetric, and microcirculatory information with serial echocardiography. No single monitoring modality adequately captures the hemodynamic complexity of ECMO patients; instead, informed interpretation of complementary parameters and longitudinal trends is essential to guide individualized clinical decision-making and avoid delayed recognition of ventricular failure or regional hypoperfusion.

Extracorporeal membrane oxygenation (ECMO) is often the last resort for escalation of treatment in patients with severe acute respiratory distress syndrome (ARDS). The success of treatment is mainly determined by patient-specific factors, such as age, comorbidities, duration and invasiveness of the pre-existing ventilation treatment as well as the expertise of the treating ECMO center. In particular, the adjustment of mechanical ventilation during ongoing ECMO treatment remains controversial. Although a reduction of invasiveness of mechanical ventilation seems to be reasonable due to physiological considerations, no improvement in outcome has been demonstrated so far for the use of ultraprotective ventilation regimens.

Venovenous extracorporeal membrane oxygenation (VV-ECMO) is a lifesaving therapy in severe acute respiratory distress syndrome (ARDS). Unfortunately, bleeding and thrombotic complications occur regularly due to coagulation disorders associated with the device, the underlying disease, and the anticoagulation management. To facilitate a personalized approach to hemostasis in individuals receiving ECMO support, it is essential to assess the coagulative state of the patient while simultaneously taking into account the underlying medical condition and administered therapies.

High-risk acute pulmonary embolism (PE) is a life-threatening condition necessitating hemodynamic stabilization and rapid restoration of pulmonary perfusion. In this context, evidence regarding the benefit of advanced circulatory support and pulmonary recanalization strategies is still limited. In this observational study, we assessed data of 1060 patients treated for high-risk acute PE with 991 being included in a target trial emulation to investigate all-cause in-hospital mortality estimates with different advanced treatment strategies. The four treatment groups consisted of patients undergoing (I) veno-arterial extracorporeal membrane oxygenation (VA-ECMO) alone (n = 126), (II) intrahospital systemic thrombolysis (SYS) (n = 643), (III) surgical thrombectomy (ST) (n = 49), and (IV) percutaneous catheter-directed treatment (PCDT) (n = 173). VA-ECMO was allowed as bridging to pulmonary recanalization in groups II, III, and IV. Marginal causal contrasts were estimated using the g-formula with logistic regression models as the primary approach. Sensitivity analyses included targeted maximum likelihood estimation (TMLE) with machine learning, inverse probability of treatment weighting (IPTW), as well as variations of estimands, handling of missing values, and a complete target trial emulation excluding the VA-ECMO alone group. In the overall target trial population, the median age was 62.0 years, and 53.3

We performed a comparative study of the effects of X-ray irradiation and bleomycin on the mRNA levels of E-cadherin and tight junction proteins (claudin-3, claudin-4, claudin-18, ZO-2, and occludin) in an alveolar epithelial cell line L2. Irradiation decreased claudin-4 levels and increased occludin levels, while the levels of other mRNAs remained unchanged. Bleomycin increased the expression levels of all proteins examined except claudin-3. Irradiation and bleomycin have different effects on the expression level of intercellular junction proteins, indicating different reactions triggered in alveolar epithelial cells and a great prospects of further comparative studies.

Bleeding events in patients receiving direct oral anticoagulation (DOAC) can be life-threatening even at therapeutic DOAC plasma concentrations, as anticoagulation impairs hemostasis and should therefore be identified immediately after hospital admission. The anticoagulatory effects of DOAC are typically not measurable in standard coagulation tests, such as PT or aPTT. Specific calibrated anti-FXa-tests allow specific drug monitoring, but they are too time-consuming for critical bleeding events and are commonly not available for 24 h/7 days in routine care. However, recent advances in point-of-care (POC) viscoelastic testing (VET) have shown a promising approach for rapid and quantitative detection of DOAC plasma concentrations using the Russell viper venom factor V activator (RVV for FXa-inhibitors) test or the ecarin clotting time (thrombin inhibitors). In acute bleeding situations, direct FXa inhibitors can be reversed by specific antidote andexanet alfa or hemostasis can be improved by prothrombin complex factor concentrates (PCCs). After reversal, confirmation of reversal efficacy is often requested, but no routine assays are currently available. Thus, the emergency management of bleeding DOAC patients is usually “blinded” with regard to reversal efficacy. POC VET laboratory assays might therefore also be helpful for measuring DOAC effects after reversal. We present a case series demonstrating the usefulness of RVV-clotting time post-DOAC reversal with andexanet alfa.

The prone position is an immediately available and easily implemented procedure that was introduced more than 50 years ago as a method for improvement of gas exchange in patients with acute respiratory distress syndrome (ARDS). In the meantime, a survival advantage could also be shown in patients with severe ARDS, which led to the recommendation of the prone position for treatment of severe ARDS by expert consensus and specialist society guidelines. The continuing coronavirus disease 2019 (COVID-19) pandemic moved the prone position to the forefront of medicine, including the widespread implementation of the prone position for awake, spontaneously breathing nonintubated patients with acute hypoxemic respiratory insufficiency. The survival advantage is possible due to a reduction of the ventilator-associated lung damage. In this article, the physiological effects, data on clinical results, practical considerations and open questions with respect to the prone position are discussed.

BACKGROUND:In-hospital mortality of septic critically ill patients with COVID-19 is significantly higher than in those without COVID-19. The knowledge on long-term outcomes remains scarce. In this retrospective analysis, we compare clinical characteristics, long-term functional outcomes, and survival in septic critically ill patients with and without COVID-19. METHODS:Data of septic critically ill patients without COVID-19 were collected as part of the Comprehensive Sepsis Center Dresden-Kreischa registry from 2020 to 2023. The data of septic critically ill patients with COVID-19 were collected as part of the local ARDS/COVID-19 registry over the same period. Diagnosis of sepsis was based on the Sepsis-3 definition. Variables collected for analyses were obtained from electronic health records. Long-term follow-up was performed 6-12 months after sepsis diagnosis. Survival was depicted using Kaplan-Meier curves. Associations between long-term mortality and risk factors were modeled by Cox Regression. RESULTS:372 septic patients without COVID-19 and 301 with COVID-19 were enrolled. Septic patients with COVID-19 were significantly younger, had a significantly lower Charlson Comorbidity Index, and had a significantly higher SOFA score at ICU admission. Long-term follow-up showed a significantly higher mortality in septic patients with COVID-19 (73.4 % vs. 30.1 %; HR 3.4 (95 % CI 2.73-4.27; p < 0.05)). COVID-19 infection was associated with significant increased mortality (adjusted HR 3.27; 95 % CI 2.48-4.33; p < 0.05) and reduced health-related quality of life, measured by the EQ-5D-3 L Index, (0.56 (0.16-0.79) vs. 0.79 (0.69-0.99); p < 0.05). CONCLUSIONS:In our cohort of septic critically ill patients, health-related quality of life and long-term survival were considerably reduced in patients with concomitant COVID-19. Furthermore, COVID-19 could be identified as an independent risk factor for higher long-term mortality in these patients.

Surgical site infections (SSI) are the most frequent cause of impaired perioperative wound healing, lead to increased postoperative morbidity, mortality and length of hospital stay and are therefore a relevant perioperative complication. In addition to numerous measures taken by the surgical departments, there are anesthesiological options that can help to reduce the risk of SSI. In addition to heat, volume and transfusion management these include, for example, the use of antibiotics and the choice of the anesthesia procedure. This article is intended to provide fundamental knowledge on SSI, shows various options for reducing them in the context of anesthesia and evaluates their effectiveness and evidence based on the current state of knowledge.

Sowohl der inner- als auch außerklinische Herzkreislaufstillstand ist mit einer hohen Letalität assoziiert. Die Optimierung der Rettungskette und der Postreanimationsbehandlung konnte in der Vergangenheit Überlebensvorteile für die Patient*innen erreichen. Für Patient*innen im therapierefraktären Herz-Kreislauf-Stillstand gab es bislang jedoch kaum aussichtsreiche Behandlungsmöglichkeiten. Für ausgewählte Patient*innen im therapierefraktären Herz-Kreislauf-Stillstand, die mit konventioneller kardiopulmonaler Reanimation (CPR) keinen „return of spontaneous circulation“ erzielen, ist die extrakorporale (e)CPR mithilfe venoarterieller extrakorporaler Membranoxygenierung eine Möglichkeit, die Überlebenswahrscheinlichkeit zu verbessern. Der vorliegende Beitrag beschreibt technische Besonderheiten, wichtige Aspekte der Therapie und die aktuelle Datenlage zur eCPR bei Patient*innen mit inner- bzw. außerklinischem Herz-Kreislauf-Stillstand.

Small, portable hand-held ultrasound devices nowadays enable a widespread use of prehospital point-of-care ultrasound (pPOCUS), which has so far only been used hesitantly, especially in ground-based emergency services. Many critical or even life-threatening conditions or internal injuries can often be better diagnosed or ruled out using pPOCUS, which can enable faster and more suitable goal-directed treatment and hospital transport. This article critically discusses relevant data, clinical benefits, limitations and challenges to be overcome when using pPOCUS for the most important life-threatening situations and aims to call for intensifying training and the extensive use of pPOCUS.

Kleine transportable Hand-held-Ultraschallgeräte ermöglichen heutzutage einen breiten Einsatz des prähospitalen Point-of-care-Ultraschalls (pPOCUS), der jedoch bislang v. a. im bodengebundenen Rettungsdienst nur zögerlich Anwendung findet. Viele kritische oder gar lebensbedrohliche Krankheitsbilder bzw. innere Verletzungen können mittels pPOCUS oft besser diagnostiziert oder ausgeschlossen werden, was eine schnellere und gezieltere Therapie und Klinikzuweisung ermöglichen kann. Dieser Leitartikel beleuchtet kritisch relevante Daten, den klinischen Nutzen, Limitationen und zu bewältigende Herausforderungen bei der Anwendung von pPOCUS bei den wichtigsten lebensbedrohlichen Leitsymptomen und soll dazu auffordern, die Ausbildung und den flächendeckenden Einsatz von pPOCUS zu intensivieren.

Objective: To describe health-related quality of life and participation after rehabilitation of severely affected sepsis survivors. Design: Cohort study. Subjects/Patients: Patients with severe sequelae after sepsis treated in a multidisciplinary rehabilitation pathway were included. Methods: Patient characteristics at the time of diagnosis, and the outcome 3 months after discharge from rehabilitation are described. At that time, health-related quality of life, social participation, and the rate of living at home were measured. Results: Of the 498 patients enrolled, 100 severely impaired patients were transferred for a multidisciplinary rehabilitation approach. Fifty-five of them were followed up at 3 months. Descriptive and inference statistics showed that 69% were living at home with or without care. Health-related quality of life and participation scores were 0.64 ± 0.32 for the EQ-5D utility index and 54.98 ± 24.97 for the Reintegration of Normal Living Index. A multivariate regression model explaining health-related quality of life at 3 months included age, lower limb strength, and walking ability during rehabilitation (r2 = 0.5511). Participation at 3 months was explained by age, body mass index, lower limb strength, and duration of tracheal intubation (r2 = 0.6229). Conclusion: Patients who have experienced serious sepsis with severe sequelae can achieve a moderate level of quality of life and participation within a multidisciplinary pathway.

Die Bauchlagerung ist eine sofort zugängliche und leicht umsetzbare Prozedur, die vor mehr als 50 Jahren als Methode zur Verbesserung des Gasaustausches bei Patienten im akuten Lungenversagen (ARDS) eingeführt wurde. Mittlerweile konnte auch ein Überlebensvorteil bei Patienten mit schwerem ARDS gezeigt werden; dies führte zur Empfehlung der Bauchlagerung bei der Behandlung von schwerem ARDS durch Expertenkonsens und fachgesellschaftliche Leitlinien. Die anhaltende COVID-19-Pandemie hat die Bauchlagerung weiter in den Vordergrund der Medizin gerückt, einschließlich der weit verbreiteten Umsetzung der Bauchlagerung bei wachen, spontan atmenden, nichtintubierten Patienten mit akuter hypoxämischer Ateminsuffizienz. Der Überlebensvorteil ergibt sich möglicherweise durch eine Reduktion des beatmungsassoziierten Lungenschadens. Im vorliegenden Beitrag werden die physiologischen Effekte, Daten zu klinischen Ergebnissen, praktische Überlegungen und offene Fragen zur Bauchlagerung diskutiert.

BACKGROUND:The direct thrombin inhibitor argatroban is indicated for the treatment of heparin-induced thrombocytopenia II, but it is also used off-label to treat critically ill patients presenting with heparin resistance, severe antithrombin deficiency, or hypercoagulability. Direct drug monitoring is not routinely available, and argatroban dosing is mainly based on global coagulation assays such as activated partial thromboplastin time (PTT) or diluted thrombin time (TT), both of which have limitations in patients with hypercoagulability. METHODS:Blood samples were obtained from critically ill patients treated with argatroban. Activated PTT and diluted TT were measured with a STA R Max3 analyzer (STAGO Deutschland GmbH, Germany) using an argatroban-calibrated kit. Ecarin clotting time was measured using a point-of-care viscoelastic test device. Liquid chromatography with tandem mass spectrometry was performed using a reversed-phase column, a solvent gradient, and an API4000 mass spectrometer with electrospray. Correlation was described using Pearson correlation coefficient r and Bayesian multilevel regression to estimate relationships between outcomes and covariates. RESULTS:From June 2021 to March 2022, 205 blood samples from 22 patients were analyzed, allowing for 195 activated PTT-liquid chromatography with tandem mass spectrometry comparisons, 153 ecarin clotting time-liquid chromatography with tandem mass spectrometry comparison, and 105 diluted TT-liquid chromatography with tandem mass spectrometry comparisons. Compared to liquid chromatography with tandem mass spectrometry, performance of argatroban quantification was best for diluted TT (r = 0.91), followed by ecarin clotting time (r = 0.58) and activated PTT (r = 0.48). Regression analysis revealed that patients with sepsis were more prone to argatroban overdosing (coefficient, 4.194; 95% credible interval, 2.220 to 6.792). CONCLUSIONS:Although activated PTT monitoring of argatroban is the most commonly used test, in critically ill patients, diluted TT provides more precise measurements. Alternately, point-of-care viscoelastic ecarin clotting time also provides guidance for argatroban dosing to identify overdosing if available. The data also suggested that patients with sepsis are at greater risk for argatroban overdosing. EDITOR’S PERSPECTIVE: