OBJECTIVE:A definition of refractory septic shock is necessary to guide diagnosis, management, prognostication, research, and future guidelines for this most severe form of the disease. We sought to achieve consensus on clinical criteria that would be used to define refractory septic shock. DESIGN:Review of literature, expert panel position statements, and Delphi rounds with an international expert group. SETTING:Consensus was defined as having at least 75% of panellists in agreement or disagreement on the three highest or lowest levels of a 7-point Likert scale or based on responses to single- or multiple-choice questions, respectively. SUBJECTS:A panel of multinational, multiprofessional and multidisciplinary critical care experts assembled by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine (57 invitations and 56 participants). MEASUREMENTS AND MAIN RESULTS:A five-round Delphi process was conducted for consensus and stability. The steering committee proposed 34 statements, and five of them were rejected by panel experts after round 2. Among 29 statements selected from eight domains, consensus was reached for 13. The panel agreed on the need for a comprehensive consensus set of clinical criteria for refractory septic shock. Markers of organ dysfunction (75%, 2 rounds), tissue perfusion (91.1%, 2 rounds) including lactate (94.6%, 2 rounds) and capillary refill time (76.8%, 2 rounds), assessment of fluid-responsiveness after initial resuscitation (92.9%, 5 rounds), and use of vasoactive drugs at norepinephrine equivalents greater than 0.5 µg/kg/min (75.0%, 3 rounds), were selected as clinical criteria of refractory septic shock. The use of critical care ultrasound (CCUS) (92.9%, 3 rounds) was the single diagnostic modality that reached a consensus-based agreement. CONCLUSIONS:A consensus for 13 criteria to frame the definition of refractory septic shock was reached. Refractory septic shock is characterised by persistently elevated lactate concentrations and or prolonged capillary refill time in patients with septic shock who are fluid unresponsive, require a norepinephrine base equivalent dose greater than 0.5 micrograms per kilogram per minute, and undergo CCUS assessment when mixed shock is suspected.

BACKGROUND:Intensive care unit (ICU) admission of obstetric patients during pregnancy or postpartum is not uncommon. The long-term physical and emotional implications of such admissions require elucidation. AIM:To describe obstetric patients' long-term perspectives on ICU admission and recovery. METHODS:A phenomenological approach was undertaken. All consecutive obstetric patients admitted to the ICU during 2016-2021 were invited to participate in a semi-structured interview after hospital discharge. Interviews were conducted from 12/2020 to 06/2022, and the transcripts were analyzed using Braun and Clarke's six-phase approach to reflexive thematic analysis. RESULTS:A total of 59 women aged 20-34 years admitted to an ICU during pregnancy or postpartum were interviewed. Qualitative inductive analysis of the interview transcripts generated three themes: the illness experience, an atypical patient, and recovery. Repetitive topics were a sense of disorientation, feeling distressed and scared, the importance of remaining in contact with and informed on the neonate, the importance of partner and family support, the challenges of being an atypical ICU patient, the difficulties in returning to normal life, and coping strategies. CONCLUSIONS:This study sheds new light on the experiences of obstetric patients admitted to an ICU. It highlights missed opportunities for maternal‑neonatal bonding, the importance of family support, unique needs that often remain unmet, the need for effective communication with the ICU staff, and the physical and emotional long-term adverse effects of the experience. The patient's narrative can contribute to our understanding of the ICU experience as a whole and its outcomes.

Dual-energy computed tomography (DECT) acquires images at two X-ray energy levels, enabling material differentiation beyond conventional single-energy CT. DECT generates iodine maps, virtual non-contrast images, and other reconstructions that enhance diagnostic performance while reducing contrast dose and radiation exposure. These advantages are particularly relevant for critically ill patients, where accurate and rapid imaging with reduced contrast exposure can be organ or life saving.This review summarizes current evidence on DECT in critical care. In pulmonary embolism, DECT provides anatomical and functional assessment through iodine perfusion maps, improving detection of segmental and subsegmental emboli. In post-thrombectomy intracerebral hemorrhage, DECT can distinguish true hemorrhage from post-procedural contrast staining. In acute abdominal pathology, DECT can improve visualization of ischemia, inflammation, infection, and hemorrhage. In urolithiasis, DECT can identify uric acid stone composition, informing treatment selection. In aortic imaging, DECT may improve diagnostic confidence while enabling iodine dose reduction and substitution of true non-contrast scans with virtual alternatives. In musculoskeletal imaging, DECT accurately detects bone marrow edema, potentially reducing the need for magnetic resonance imaging when access is limited. DECT also has applications in tendon and ligament injury, and metal artifact reduction.Across these scenarios, DECT offers advantages over conventional CT in critical care, including material differentiation, functional assessment, and potential reductions in contrast dose and radiation exposure. It generally demonstrates high specificity and variable sensitivity, with the level of supporting evidence varying by indication, ranging from meta-analyses to small retrospective studies. Wider adoption will require standardized protocols, targeted training, and additional high-quality studies.

Current evaluations of large language models (LLMs) in healthcare have largely emphasized theoretical benchmarks and clinician oversight, with limited exploration of real-world physician-AI interaction. In this two-stage prospective study, we assessed physician satisfaction with LLM-generated responses to real clinical queries. This study did not evaluate clinical accuracy, patient outcomes, or patient safety. In the first unblinded stage, physicians used three models - a general-purpose model (GPT-4o), a reasoning-focused model (GPT-o1), and a healthcare-specific model (OpenEvidence) - to address 25 clinical dilemmas - and rated the quality of the responses. In the second blinded stage, the same physicians evaluated responses generated either by an LLM or by a human alone, without knowledge of the source. Across 100 real-world medical responses, median physician scores on a 5-point Likert scale were comparable between unblinded and blinded evaluations (p = 0.90). Satisfaction was not associated with physicians' resistance to change, nor did it correlate with the accuracy or relevance of cited literature. These findings suggest that physicians did not favor information generated by LLMs over externally provided responses, and that clinician satisfaction alone may not serve as a reliable proxy for validating decision support tools.

Background:Hypoglycemia in pregnancy is relatively understudied, with conflicting evidence suggesting either outcomes similar to normal oral glucose tolerance test (OGTT) or associations with poor neonatal outcomes. Maternal glucose crosses the placenta, thus maternal hypoglycemia may affect the fetus. Objective:This study aimed to evaluate the association between maternal hypoglycemia and neonatal birth weight, specifically the risk of small-for-gestational-age (SGA) neonates, and to examine maternal metabolic outcomes in comparison to normoglycemic and hyperglycemic individuals. Study Design:This retrospective cohort study included 39,306 primiparous individuals aged 18-50 years. Participants were classified as hypoglycemic (glucose <70 mg/dL) hyperglycemic (≥1 abnormal OGTT value), or normoglycemic. The primary outcome was the rate of SGA (<10th percentile) and large-for-gestational-age (LGA, >90th percentile) neonates. Secondary outcomes included maternal hypertensive disorders, gestational diabetes requiring treatment (GDMA2), and long-term risk of diabetes mellitus (DM). Results:Among the cohort, 16,062 (40.9%) were hypoglycemic, 8543 (21.7%) were hyperglycemic, and 14,701 (37.4%) were normoglycemic. Compared to normoglycemic individuals, hypoglycemia was associated with an increased likelihood of SGA (OR 1.2, 95% CI 1.1-1.4), particularly in the second and third trimesters. Hyperglycemia was associated with an increased likelihood of LGA (OR 1.2, 95% CI 1.1-1.4). Hypoglycemia was also linked to a higher prevalence of gestational diabetes (GDMA2) and dysglycemia during pregnancy, yet a lower likelihood of developing DM later in life compared to hyperglycemic individuals. Conclusion:Maternal hypoglycemia during pregnancy is associated with an increased risk of SGA neonates and may serve as an early marker of underlying glucose dysregulation. Given these findings, repeated glucose monitoring and closer follow-up for individuals with hypoglycemia may be warranted. Future research should investigate long-term neonatal and maternal metabolic outcomes to refine clinical management strategies for hypoglycemia in pregnancy.

RATIONALE:Neuromuscular blocking agents (NMBAs) show potential benefits on mortality and other complications of acute respiratory distress syndrome (ARDS) in adult patients. Evidence-based decisions and processes ensure appropriate use of neuromuscular blockade in adult patients with ARDS. OBJECTIVES:The objective of these guidelines was to develop evidence-based recommendations for the administration of NMBAs in critically ill adult patients with ARDS. DESIGN:The American College of Critical Care Medicine Board convened a 21-member multidisciplinary panel of experts in critical care medicine, nursing, respiratory therapy, pharmacology, surgery, neurology, and anesthesiology. The panel included two expert methodologists specialized in developing evidence-based recommendations in alignment with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Conflict-of-interest policies were strictly followed during all phases of guidelines development including task force selection and voting. METHODS:The panel members identified and formulated five Population, Intervention, Comparison, and Outcome questions. We conducted a systematic review for each question to identify the best available evidence, statistically analyzed the evidence, and assessed the certainty of the evidence using the GRADE methodology. We used the GRADE evidence-to-decision framework to formulate the recommendations. RESULTS:The panel generated two conditional recommendations. One recommendation is to use NMBAs in adults with ARDS with Pao2/Fio2 less than 150. For the other recommendations, there was equipoise in the recommendation for and against using titratable vs. fixed-dose NMBA dosing, a monitoring-based strategy for assessing depth of sedation and analgesia in adults with ARDS before initiating or while receiving neuromuscular blockade, and administration of NMBAs for patients who are proned, due to overall lack of evidence in critically ill patients and due to considerations of patient safety and experience concerns. CONCLUSIONS:These guidelines provide additional perspectives on the use of NMBA in patients with ARDS, recognizing that institutional and patient-specific considerations must help to guide the decision-making process.

Introduction The rate of intensive care unit (ICU) admission of obstetric patients in high-income countries is approximately 0.4%. ICU admission can negatively affect quality of life (QoL). Aim To assess survival status of obstetric patients admitted to ICU. Secondary outcomes included domiciliary status and QoL versus matched controls without ICU admission. Methods Bi-center, cross-sectional questionnaire study of patients admitted to an ICU and controls of non-ICU patients, matched for date of admission, demographics, obstetric history and neonatal outcome. Survival was determined via the Central National Population Registry. QoL and postpartum depression (PPD) were assessed at hospital discharge and at time of interview. Post-Traumatic Stress Disorder (PTSD) was assessed up to the time of interview. Results Among 216 ICU admission, seven died (3.2%). Overall, 128 patients were interviewed (64 ICU patients vs. 64 non-ICU patients). All participants were living at home. ICU survivors had lower QoL at the time of hospital discharge (42.6 ± 22.4 vs. 60.2 ± 18.9, p < 0.001) compared to non-ICU controls, but by the time of interview QoL was similar between cohorts. ICU survivors also had higher rates of PPD at hospital discharge (51.6% vs. 17.2%, p < 0.001) and at interview (12.5% vs. 0%, p = 0.003) and higher rates of PTSD versus controls (10.9% vs. 1.6%, p = 0.030). Conclusion In this study, one in thirty ICU obstetric patients died. Critical illness with ICU admission carried short- and long-term implications in terms of QoL and psychological morbidity. Most patients reported improvement over time, but this process spanned months to years.

To compare cesarean delivery rates and induction outcomes among women undergoing labor induction with a cervical ripening double balloon (DB), oral misoprostol (OM), or a combination of both (DOM). This single-center randomized controlled trial included women with singleton term pregnancies, cephalic presentation, Bishop score ≤ 4, and intact membranes. Participants were randomized to DB for 6 h, oral misoprostol, or combined treatment. The primary outcome was cesarean delivery rate. Secondary outcomes included Bishop score after 6 h, time from induction to delivery, failed induction, and maternal and neonatal outcomes. Due to slow recruitment, the study was stopped early, and complete-case analysis was performed. A total of 216 participants were included in the analysis (DB n = 65, OM n = 75, DOM n = 76). Cesarean delivery rates were 20

The breakage of an intravenous (IV) cannula represents a rare complication associated with peripheral IV cannulation, a prevalent procedure in the civilian and military prehospital setting. Intravenous cannula breakage can lead to further complications including infection, migration, and subsequent embolization. Although fast identification and extraction are essential management components, there are no consensual guidelines for the proper management of this complication. In this report, we present a case involving a 19-year-old soldier who presented to the emergency department following the rupture of an IV cannula during military training. Subsequently, embolization of the cannula fragment occurred because of the patient's discomfort and noncompliance with venous tourniquet usage. This case report delineates the actions taken both on-site and upon the patient's arrival in the emergency room, including the utilization of point-of-care ultrasound as an expedient diagnostic tool for identifying the fragmented cannula swiftly. Additionally, we provide a review of the management approaches detailed in existing literature, with a specific emphasis on the use of venous tourniquet placement as a potential measure for avoiding complications.

Artificial Intelligence (AI) is rapidly transforming the landscape of critical care, offering opportunities for enhanced diagnostic precision and personalized patient management. However, its integration into ICU clinical practice presents significant challenges related to equity, transparency, and the patient-clinician relationship. To address these concerns, a multidisciplinary team of experts was established to assess the current state and future trajectory of AI in critical care. This consensus identified key challenges and proposed actionable recommendations to guide AI implementation in this high-stakes field. Here we present a call to action for the critical care community, to bridge the gap between AI advancements and the need for humanized, patient-centred care. Our goal is to ensure a smooth transition to personalized medicine while, (1) maintaining equitable and unbiased decision-making, (2) fostering the development of a collaborative research network across ICUs, emergency departments, and operating rooms to promote data sharing and harmonization, and (3) addressing the necessary educational and regulatory shifts required for responsible AI deployment. AI integration into critical care demands coordinated efforts among clinicians, patients, industry leaders, and regulators to ensure patient safety and maximize societal benefit. The recommendations outlined here provide a foundation for the ethical and effective implementation of AI in critical care medicine.

Acute kidney injury (AKI) is a prevalent condition in ICU patients. However, inconsistencies in urine charting and guideline interpretations hinder accurate diagnosis and research. This study aimed to derive and validate a standardization for the processing of big urine output datasets to improve consistency in AKI diagnosis and staging. Using a derivation cohort from 14 ICUs at Beth Israel Deaconess Medical Center (2008–2019) and a validation cohort from an academic center in Amsterdam (2003–2016), we developed and validated an algorithm for computing hourly urine output rates and identifying oliguric AKI across its definitions. Peak AKI stages computed using the method were significantly associated with all clinical outcomes, including severity scores, serum creatinine levels, ICU and hospital lengths of stay, renal replacement therapy requirements, and hospital mortality (all p < 0.001). Adjusted 30-day mortality odds ratios for AKI stages 1–3 were 1.58, 2.93, and 5.24 in the derivation cohort and 2.91, 5.16, and 13.59 in the validation cohort (all p < 0.001). Tested on over 85,000 multinational ICU admissions, this approach demonstrated robust performance and consistent results across diverse settings; it has the potential to enhance clinical practice through e-alerts and support future AKI and fluid balance research, including ML model training and inference. Supported by open-source code, the proposed method advances the standardization of AKI diagnostic criteria and can be applied to other EHR-based databases.

Whether large language models (LLMs) can resolve real-world dilemmas faced by clinicians remains unclear and physician quality assessment is often used as a measure of LLM output quality. We compared reports - defined as answers to clinical queries generated by LLMs or written by human researchers - generated by GPT-4o, Gemini 2.0, and Claude Sonnet 3.5 in response to such dilemmas (n = 20) to reports written by trained human researchers and studied whether physician satisfaction correlates with objective report quality. Twenty human reports and fifty-six LLM-reports were analyzed. Human reports met physicians’ expectations more frequently (p = 0.044), were considered more reliable (p = 0.032), professionally written (p = 0.003), and time-saving (p = 0.003). Human reports cited more sources (p < 0.001) and while these were from lower ranking journals (median IF: 7 [3, 11] vs 14 [10, 27], p = 0.003), they were considered more relevant (p < 0.001). Unlike LLMs, human reports contained no hallucinated (p < 0.001) or unfaithful (p < 0.001) citations. However, no meaningful correlation was identified between physician satisfaction and objective measures of report quality. A meaningful gap remains between LLM and human capacity to respond reliably and in a relevant manner to real-life clinical dilemmas. Of greater concern is that physician satisfaction with generated content is not a good measure of quality.

Sepsis is a significant global health issue, with high morbidity, mortality, and economic burden. Its definition has evolved, with the latest Sepsis-3 criteria emphasizing life-threatening organ dysfunction due to a dysregulated host response. Endothelial dysfunction plays a critical role in sepsis pathogenesis, characterized by increased permeability and inflammatory responses. Human serum albumin, the most abundant protein in the bloodstream, is essential for maintaining oncotic pressure and endothelial integrity. This narrative review provides an overview of endothelial changes during sepsis and their impact on organ damage. We also explore the role of albumin administration in managing endothelial dysfunction in sepsis and discuss the available preclinical and clinical evidence.

Cardiovascular collapse and arrest in the periprocedural setting and intensive care unit differ from arrests in other contexts (such as out-of-hospital or hospital ward) because clinicians almost always witness the event, and the most likely precipitating cause may be known. In comparison to other settings, the response can be timelier and more focused on treating the underlying cause(s). Since many patients deteriorate over minutes to hours, clinicians can evaluate the patient expeditiously, generate a diagnosis, and initiate appropriate treatment more rapidly than in other arrest circumstances. This iteration of Perioperative Resuscitation and Life Support (PeRLS) employs Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) methodology to review the most recent evidence on preventing and managing cardiac arrest during the perioperative period. Furthermore, many of the recommendations and algorithms may also be applicable to areas outside the operating room, such as the intensive care unit and emergency room.

Importance:The Sequential Organ Failure Assessment (SOFA) score was published in 1996 to describe organ dysfunction in critically ill adult patients in a readily quantifiable and sequential manner. Considerable changes have occurred over the last 3 decades in the use of organ support drugs and devices and in patient outcomes, necessitating revision of the score. Objectives:To develop definitions of organ dysfunction that reflect current understanding and to identify representative variables to generate a revised SOFA score (SOFA-2) of individual organ dysfunction. Evidence Review:A task force of experts in intensive care medicine and epidemiology generated definitions of organ dysfunction, identified relevant variables (physiological and laboratory data specific to the organ system, pharmacological and mechanical organ support), and proposed a 0 to 4-point grading of dysfunction severity through meetings, Delphi processes, and explicit rules, informed by data synthesis, including systematic reviews and meta-analysis. Variables were tested in 2 validation exercises using separate datasets totaling 3.34 million patients within 10 representative databases from diverse geographical and socioeconomic settings to assess distribution and predictive validity (mortality at intensive care unit discharge). Findings:A total of 60 experts participated, with 18 (30%) female participants. Overall, 65 countries were represented, with 33 (51%) from Europe and Central Asia, 13 (20%) from North America; and 8 (12%) from Latin America and the Caribbean. The physiological variables within the 6 organ systems used in the original SOFA score were retained, although some categories were renamed (ie, central nervous system was changed to brain, renal to kidney, coagulation to hemostasis, and hepatic to liver). Revisions of organ support drug and device variables were made to reflect current practice. Alternative variables were added for instances when laboratory data and/or organ support interventions would be inaccessible (eg, in some low-resource settings) or not indicated (eg, ceiling of treatment). Some point cutoff thresholds were modified based on evidence from systematic reviews and data analyses. Scores could not be developed for 2 additional organ systems (gastrointestinal and immune) due to insufficient data, complexity, or lack of content and predictive validity for the variables assessed. Explicit rules were developed to facilitate scoring consistency. Conclusions and Relevance:Through a methodologically robust development process, the SOFA-2 score offers updated definitions to describe organ dysfunction in adult patients requiring critical care and readily quantifiable criteria to grade the degree of dysfunction in individual organ systems. This score considers contemporaneous changes in patient management and outcomes.

These European Resuscitation Council (ERC) Guidelines 2025 on Special Circumstances in Resuscitation are based on the 2025 Consensus on Science with Treatment Recommendations (CoSTR) of the International Liaison Committee on Resuscitation (ILCOR), reviews by the expert writing group and relevant peer-reviewed literature. The guideline chapter provides guidance for laypeople and healthcare professionals on the modifications required to basic and advanced life support in adults for the prevention and treatment of cardiac arrest for in-hospital and out-of-hospital cardiac arrest. The ERC Guidelines 2025 Paediatric Life Support cover the special circumstances in children.

BACKGROUND:Environmental events, including military conflicts, may dramatically affect a hospital's ability to provide routine treatments while maintaining reasonable waiting times. OBJECTIVE:To examine the impact of a military conflict ("Protective Edge", PE) on the volume of activity and waiting times for outpatient clinics in a tertiary medical center. METHODS:Outpatient visits during PE (July-August 2014) were compared to outpatient visits during July-August 2013 (pre-conflict period) and 2015 (post-conflict period) with regards to the daily number of visits and waiting times. Clinics with at least 5,000 annual visits were included. Quantile regression adjusted for confounders was used for the multivariable models, in a stratified analysis by specialty. RESULTS:There were 87,495 outpatient visits during PE and 197,029 visits during the pre- and post-conflict periods. An 11% decrease in the daily number of visits was noted (ranging from 6% decrease in oncology and cardiology to 19-20% decrease in psychiatry and pediatrics). During PE, statistically significant longer waiting times were found for surgery (+1.0 day) and imaging (+1.1 days), while a 2.4 days decrease was noted in pediatrics, controlled for age, sex, ethnicity and the daily number of visits. Median waiting times were unchanged for cardiology, medicine, psychiatry and cardiology. CONCLUSIONS:In the midst of a continuing military conflict, there was a notable increase in outpatient visit waiting times in some disciplines, but not all, despite a reduction in the overall volume of visits. Investigating whether similar impacts on patient care occur during other military conflicts or pandemics necessitates further research.