Background:Patients with severe respiratory failure frequently suffer from concomitant haemodynamic compromise. By correcting respiratory acidosis and permitting reduced mechanical ventilation pressures, venovenous extracorporeal membrane oxygenation (V-V ECMO) may indirectly improve haemodynamics. The aim of this study was to assess how vasopressor requirements changed after V-V ECMO cannulation, and which factors were the primary drivers of this change. Methods:This retrospective single-centre study included 107 consecutive adult recipients of V-V ECMO from 2010 to 2024 who required noradrenaline within 24 h before ECMO cannulation. The primary outcome was the change in Vasoactive-Inotropic Score (VIS) from Day 0 (24 h before) to Day 1 (24 h after ECMO initiation). Secondary outcomes included changes in fluid balance, ventilator settings, blood gas and laboratory parameters. A linear mixed-effects model was used to assess the effects of daily net fluid balance, mean airway pressure (Paw), mean daily pH, arterial partial pressure of oxygen (PaO2), arterial partial pressure of carbon dioxide (PaCO2), mean daily propofol dose, and lactate on the VIS over time ("Day -2" to "Day +3"). Results:From Day 0 to Day 1, the daily mean VIS significantly decreased from a median of 14 (IQR 6, 30) to a median of 12 (5, 22). This was accompanied by significant reductions in Paw and PaCO₂, and a significant increase in arterial pH (p < 0.001 for all). In the multivariate model, a higher arterial pH was significantly associated with a lower VIS (β = -9.2 per +0.1-unit, p < 0.001). Higher lactate was associated with higher VIS (β = 4.5, p < 0.001). Sensitivity analyses revealed more pronounced effects of pH increase on VIS reduction in patients with high noradrenaline requirements. Conclusions:After initiation of V-V ECMO, a significant decrease in vasopressor requirements was observed, this benefit being directly attributable to the correction of severe respiratory acidosis.

BACKGROUND:Extracorporeal membrane oxygenation (ECMO) is a life-saving intervention for patients with severe cardiac or respiratory failure, but it is associated with a high risk of thrombotic and bleeding complications. Unfractionated heparin (UFH) remains the most frequently used anticoagulant, largely due to historical practice and longstanding clinical familiarity, despite the absence of robust evidence from randomized controlled trials. Alternative strategies-including direct thrombin inhibitors (DTIs), low-molecular-weight heparins (LMWHs), nafamostat mesylate (NM), and no anticoagulation-are increasingly being explored. However, a comprehensive and contemporary comparison of these approaches has been lacking. METHODS:We conducted a comprehensive search of PubMed/MEDLINE, EMBASE, and CENTRAL through March 2025, supplemented by manual searches of reference lists. We included randomized controlled trials and observational studies including patients 16 years or older receiving ECMO for ≥ 24 h that compared any anticoagulation strategy with another or with no anticoagulation. The primary outcome was thromboembolic events; secondary outcomes included bleeding and mortality. Risk of bias was assessed using validated tools. Meta-analyses were performed using a multivariable random-effects model, with prespecified subgroup analyses by ECMO modality (venoarterial [VA], venovenous [VV], or mixed) and subsequent sensitivity analyses. RESULTS:Twenty-one observational studies involving 2 775 adult ECMO patients were included, with UFH serving as the comparator in all studies. DTIs showed reduced thromboembolism (OR 0.73; 95% CI: 0.53-0.99) and were associated with significantly lower bleeding (OR 0.51; 95% CI: 0.39-0.67) and mortality (OR 0.70; 95% CI: 0.52-0.94), confirmed in a sensitivity analysis. LMWH was associated with significantly reduced odds of thromboembolic events (OR 0.26; 95% CI: 0.13-0.55), as well as showing a favorable bleeding profile (OR 0.46; 95% CI: 0.25-0.87), yet no significant difference in mortality (OR 0.80; 95% CI: 0.30-2.14). While no anticoagulation reduced the odds for bleeding (OR 0.17; 95% CI: 0.07-0.38) and NM showed no significant differences, both had wide confidence intervals, limiting interpretation. Heterogeneity for LMWH was low for efficacy and bleeding, yet substantial for mortality; for DTI, low to moderate; for no anticoagulation, low; and for NM, substantial to high on all comparisons. CONCLUSIONS:In this systematic review and meta-analysis, DTIs and LMWH appear to be effective and safe alternatives to UFH in adult ECMO, with consistent reductions in thromboembolic and bleeding events and a survival benefit observed for DTIs. These findings support reconsideration of UFH as the default anticoagulant and favor a more prominent role for alternative strategies in clinical practice. TRIAL REGISTRATION:PROSPERO CRD42022363588.

Aims Cangrelor is used to bridge the gap of insufficient platelet inhibition in patients with out-of-hospital cardiac arrest (OHCA) undergoing percutaneous coronary intervention (PCI).Methods and results In a retrospective chart review study, we investigated the incidence of bleeding and stent thrombosis in patients with OHCA undergoing PCI who received either cangrelor and transition to an oral P2Y12 inhibitor or an oral P2Y12 inhibitor alone. Subgroups consisted of patients treated with conventional cardiopulmonary resuscitation (CPR) and extracorporeal CPR. The primary endpoint was Bleeding Academic Research Consortium (BARC) 3-5 bleeding at 30 days. Between January 2016 and March 2025, 414 patients were included of which 267 received cangrelor and an oral P2Y12 inhibitor and 147 received an oral P2Y12 inhibitor alone. BARC 3-5 bleeding at 30 days occurred at a similar rate in the cangrelor group and the oral P2Y12 inhibitor group (18.4% vs. 19.0%, respectively; adjusted OR, 0.79; 95% CI, 0.45-1.39). BARC 3-5 bleeding at 6, 24 and 48 h was similar between the cangrelor group and the oral P2Y12 inhibitor group in patients treated with conventional and extracorporeal CPR. In patients treated with extracorporeal CPR, stent thrombosis occurred less frequently in the cangrelor group compared with the oral P2Y12 inhibitor group (2.1% vs. 4.5%, respectively; adjusted OR, 0.32, 95% CI, 0.03-3.14), but without reaching statistical significance.Conclusion In patients with OHCA undergoing PCI, BARC 3-5 bleeding occurred at a similar rate in patients receiving either cangrelor and transition to an oral P2Y12 inhibitor or an oral P2Y12 inhibitor alone.

Acute exacerbations of chronic obstructive pulmonary disease (AE-COPD) requiring invasive mechanical ventilation (IMV) are associated with high mortality and long-term disability. Extracorporeal CO₂ removal (ECCO₂R) using modern high-capacity devices may facilitate early endotracheal extubation and reduce IMV-related complications. To evaluate whether ECCO2R-facilitated early extubation improves clinical outcomes compared with standard IMV in patients with severe AE-COPD requiring IMV. Adults with acute hypercapnic respiratory failure due to AE-COPD requiring IMV who failed or were ineligible for extubation within 24 hours of intubation were randomized to ECCO2R or no ECCO2R. The primary endpoint was a composite of death or severe disability at day 60. 18 patients were randomized before the trial was terminated early by the sponsor for financial reasons (planned enrollment: 192). The primary composite endpoint occurred in 0/8 ECCO2R-treated patients versus 3/9 evaluable IMV-treated patients (33

There is a notorious difficulty in judging micronutrient stores and requirements in critically ill patients and deficiency states will be rarely associated with clinical symptoms. A fundamental exception is vitamin B1, thiamine, a micronutrient of crucial importance in mitochondrial energy production. With thiamine deficiency ”the energy plug is out”, resulting in multiple organ dysfunctions, such as of brain, heart, kidney or respiratory system, lactate formation is increased, lactate clearance reduced, all fundamentally affecting the course of disease and prognosis of a patient. Several patient groups, such as malnourished subjects or patients with liver or kidney disease are already deficient prior to hospital or ICU admission, but there is also a high risk of developing deficiency during ICU stay. There are several well defined patient groups at risk, however, there is no need to measure plasma concentrations, as assays are mostly not available, costly and actually do not reflect the cellular status. There is quite solid evidence that thiamine may preserve / improve organ function (brain, heart, kidney), reduce blood lactate concentration and reduce mortality in various groups of critically ill patient. An extra thiamine supplementation should be given in high-risk patient groups, which bears no risk of inducing toxicity and is cheap, so we advocate to administer thiamine whenever a deficiency state is suspected.

Objectives Anticoagulation during extracorporeal membrane oxygenation (ECMO) remains challenging. Direct thrombin inhibitors (DTIs) such as argatroban are increasingly proposed as alternatives to unfractionated heparin (UFH). To characterize the dose titration and monitoring reliability of argatroban compared to UFH in adult ECMO patients. Methods This prespecified sub-analysis of a randomized controlled pilot trial (2021–2024) included forty adults on venovenous or venoarterial ECMO randomized to argatroban (target diluted thrombin time [dTT] 0.6–0.8 μg/ml; n=20) or UFH (target anti-factor Xa 0.2–0.3 IU/ml; n=20). The primary outcome was the pooled proportion of measurements within the therapeutic target range. Secondary outcomes included dose requirements, time to target, dose-assay correlations, and platelet count trajectories. Results Argatroban-treated patients achieved therapeutic targets significantly less often than those receiving UFH (38% vs. 51% of pooled active measurements; p<0.001). The median argatroban dose required to reach the initial target was 0.40 μg/kg/min (IQR 0.34–0.49). Correlations between anticoagulant dose and monitored effect were weak to moderate for both agents (repeated measures correlation [rrm]=0.29 for argatroban vs. dTT, and rrm=0.31 for UFH vs.anti-Xa). Both groups experienced a comparable decline in platelet counts. Conclusion In this hypothesis-generating sub-analysis, patients receiving argatroban achieved therapeutic targets less reliably than those receiving UFH. However, this variability likely reflects challenges in dosing strategy optimization and differing target stringencies rather than intrinsic pharmacokinetic instability of the drug.

Acute respiratory failure is the leading reason for intensive care unit (ICU) admission among critically ill patients with cancer. We aimed to describe the clinical characteristics, risk factors, and outcomes of patients with cancer and acute respiratory distress syndrome (ARDS) and to evaluate associations of venovenous extracorporeal membrane oxygenation (ECMO) with outcomes in the subgroup with severe ARDS. We conducted a multinational, prospective, observational cohort study of patients with cancer and ARDS in 13 countries in Europe and North America. The primary endpoint was 90-day mortality. Among 715 included patients, 73.4

Das akute Atemnotsyndrom (ARDS) ist ein heterogenes klinisches Syndrom, das sich durch eine variable Pathophysiologie und unterschiedliche therapeutische Ansätze auszeichnet. Die jüngsten Leitlinien betonen die Bedeutung der Bauchlagerung und der venovenösen extrakorporalen Membranoxygenierung (vv-ECMO) für schwerste Fälle, während routinemäßige Recruitmentmanöver und extrakorporale CO2-Eliminationsverfahren nicht mehr empfohlen werden. Um die Personalisierung der ARDS-Therapie weiter voranzutreiben, zeigt die Identifikation von ARDS-Phänotypen mittels „latent class analysis“ vielversprechende Ansätze zur personalisierten Therapie. Zudem könnten adaptive Plattformstudien und auf künstlicher Intelligenz (KI) basierende Entscheidungsunterstützungssysteme die ARDS-Behandlung optimieren. Die zukünftige ARDS-Therapie wird zunehmend individualisiert sein und auf einer verbesserten Patientenstratifizierung, neuen Studiendesigns und dem gezielten Einsatz moderner Technologien basieren. Dieser Artikel fasst die aktuellen Entwicklungen in der ARDS-Therapie zusammen, insbesondere im Hinblick auf individuelle Behandlungsstrategien, neue Studiendesigns und den Einsatz von künstlicher Intelligenz.

Das Acute Respiratory Distress Syndrome (ARDS) ist ein akut auftretendes inflammatorisches Syndrom, das zu erhöhter pulmonaler Kapillarpermeabilität mit konsekutivem interstitiellem und alveolärem Lungenödem führt. Leitsymptom ist die Hypoxämie. Die Definition umfasst den akuten Beginn, bilaterale Infiltrate und eine Verminderung des Quotienten aus arteriellem Sauerstoffpartialdruck und inspiratorischer Sauerstofffraktion (paO2/FIO2-Ratio), die auch die Einteilung in mildes (≤ 300), moderates (≤ 200) und schweres ARDS (≤ 100) bedingt. Einzige kausale Maßnahme ist die Therapie der auslösenden Ursache. Die supportive Therapie zielt auf den Erhalt des Lebens bzw. der Organfunktionen durch Gewährleistung eines adäquaten Gasaustausches, ohne zusätzlichen Schaden zuzufügen. Dazu gehören v. a. die individuell angepasste „protektive“ Beatmungstherapie und die Bauchlagerung. Bei schwerstem ARDS kann die Anwendung der venovenösen extrakorporalen Membranoxygenierung (vv-ECMO) unter strenger Indikationsstellung das Überleben verbessern.

Background: Coagulopathy is a major cause of death during extracorporeal membrane oxygenation (ECMO). Factor (F)XIII may play an important role in bleeding risk and represents a potential target for future therapies. Objectives: In order to explore the potential of using FXIII as a therapeutic target in ECMO, we assessed its activity, identified the risk factors associated with deficiency and evaluated its link to bleeding complications. Methods: This observational study investigated FXIII activity in adult ECMO patients using prospectively collected blood samples. The primary outcome was the prevalence of FXIII deficiency (<70%). Secondary outcomes included the incidence of bleeding complications according to the Bleeding Academic Research Consortium classification. Regression models were used to analyze risk factors for FXIII deficiency and its association with bleeding. Results: Between March 2020 and September 2023, FXIII activity was assessed in 101 ECMO patients undergoing a total of 108 ECMO runs. FXIII deficiency was identified in 73.3% (n = 74) of patients and occurred more frequently in those with viral infections, prolonged ECMO duration, and venovenous ECMO support. Bleeding complications were more frequent in patients with FXIII deficiency (41.9% vs 11.1%; P = .003), and the median FXIII activity was significantly associated with bleeding complications (odds ratio, 0.97 per 1% increase in activity; 95% CI, 0.94-0.99; P = .003). Similarly, minimum FXIII activity was independently associated with bleeding risk (odds ratio, 0.967; 95% CI, 0.93-0.99; P = .04). Conclusion: In this cohort of adult ECMO patients, we observed a high prevalence of FXIII deficiency. FXIII deficiency was common in adult ECMO patients and associated with viral infections, venovenous ECMO, longer ECMO duration, and bleeding; its therapeutic potential warrants further study.

Study objective Extracorporeal cardiopulmonary resuscitation (eCPR) is a rescue therapy for selected patients when conventional cardiopulmonary resuscitation (CPR) fails. Current evidence suggests that the success of eCPR depends on well-structured in- and out-of-hospital protocols. This article describes the Vienna eCPR program, and the interventions implemented to improve clinical processes and patient outcomes. Methods In this retrospective study, we report on all patients with inhospital and out-of-hospital cardiac arrest treated with eCPR at our department between 2020 and 2023. During this period, the program was restructured, including the introduction of out-of-hospital and inhospital algorithms and interprofessional training. The primary endpoint was survival with favorable neurologic outcomes at 6 months, defined as a cerebral performance category score of 1 or 2. Results Overall, 192 patients were treated with eCPR. The proportion of patients with favorable neurologic outcomes was 25% (n=48), increasing each year: 15% (5/34) in 2020, 19% (8/42) in 2021, 23% (12/53) in 2022, and 37% (23/63) in 2023. This was particularly true for out-of-hospital cardiac arrest patients: 7% (2/29), 14% (4/29), 17% (7/41), and 32% (16/50), respectively. Simultaneously, rates of witnessed arrest, bystander CPR, and initial shockable rhythm increased, whereas low-flow durations decreased. Conclusion After restructuring the Vienna eCPR program, we were able to improve survival rates with favorable neurologic outcomes after eCPR. This improvement was accompanied with increased case volumes, rates of witnessed arrest, bystander CPR, and initial shockable rhythm, and decreased low-flow durations. The learning curve we observed illustrates that outcomes can improve with experience, a summation effect of training, patient selection, and process standardization.

Acute respiratory distress syndrome (ARDS) is a heterogeneous clinical syndrome characterized by variable pathophysiology and different therapeutic approaches. Recent guidelines emphasize the importance of prone positioning and venovenous extracorporeal membrane oxygenation (VV-ECMO) for the most severe cases, while routine recruitment maneuvers and extracorporeal CO2-removal techniques are no longer recommended. To further advance the personalization of ARDS therapy, the identification of ARDS phenotypes using latent class analysis offers promising approaches for individualized treatment. Additionally, adaptive platform trials and artificial intelligence (AI)-driven decision-support systems may optimize future ARDS management. The future of ARDS treatment is becoming increasingly individualized, based on improved patient stratification, innovative study designs, and the targeted use of modern technologies. This article summarizes recent developments in ARDS therapy, particularly regarding personalized treatment strategies, new study designs, and the application of artificial intelligence.

Hematological malignancies (HMs) are increasingly associated with life-threatening complications requiring intensive care unit (ICU) management. Recent advancements in therapies, diagnostics, and critical care protocols have improved outcomes for these patients, yet significant challenges persist. This manuscript explores the evolving landscape of critical care in hematology, emphasizing the unique complications, management strategies, and future directions in the field. Patients with HMs are particularly vulnerable to infections, sepsis, organ dysfunction, and treatment-related toxicities such as cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), and coagulopathies. Innovations in the management of acute respiratory failure, septic shock, and invasive fungal infections have contributed to better survival rates, yet outcomes remain suboptimal for certain high-risk groups. Furthermore, new therapies, including CAR-T cells, bispecific antibodies, and immune checkpoint inhibitors, present both opportunities and challenges in the ICU setting due to their potential toxicities. Emerging trends emphasize the importance of early ICU admission, multidisciplinary collaboration, and precision medicine in improving patient care. The integration of biomarker-driven strategies, advanced diagnostics, and artificial intelligence holds promise for optimizing therapeutic interventions and enhancing antimicrobial stewardship. Additionally, patient-centered approaches, including time-limited trials and goal-oriented discussions, aim to balance aggressive care with quality-of-life considerations. This review underscores the need for continued research to address disparities in access to care, improve long-term outcomes, and develop standardized protocols for managing critically ill hematology patients. By advancing the integration of oncology and critical care, clinicians can better navigate the complexities of modern therapies and provide holistic, evidence-based care that aligns with patient values and priorities.

Background: Venous thromboembolism (VTE), encompassing deep vein thrombosis (DVT) and pulmonary embolism (PE), serves as a major complication in critically ill patients receiving extracorporeal life support (ECLS). The primary aim of the study was to systematically determine the prevalence of cannula-associated DVT following ECLS in a mixed adult ICU population. Methods: In this prospective diagnostic study, performed at two ICUs at a tertiary university hospital, we included 101 patients undergoing ECLS between 2016 and 2021. DVT was assessed by vascular ultrasound within 72 h after decannulation or through post-mortem examination. PE was identified by computed tomography when clinically indicated or through post-mortem examination. Both univariate analysis and multivariable logistic regression were used to evaluate risk factors. Results: The overall prevalence of DVT was 35%, and PE was found in 9% of patients. PE was significantly more frequent in patients with DVT compared to those without DVT (23% vs. 2%, p < 0.001). Logistic regression suggests venovenous configuration as an independent risk factor for DVT compared with venoarterial ECLS (OR = 0.12, 95% CI: 0.04-0.39, p = 0.0004). There were no significant differences in coagulation parameters, including anticoagulation target values, in patients with and without DVT. Conclusions: This study reveals a considerable prevalence of DVT in patients following ECLS, with VV configuration emerging as a considerable risk factor. PE was common, underscoring the need for routine screening protocols and tailored thromboprophylaxis in this population.

Viral infections, including respiratory diseases such as Coronavirus disease 2019 (COVID-19), are hypothesized to contribute to the onset of autoimmune disorders. Although elevated levels of autoantibodies have been observed following COVID-19, the role of specific autoantibodies linked to autoimmune diseases and their correlation with disease severity remains poorly defined. In this study, we used a comprehensive autoantibody panel to assess the autoantibody production across different cohorts of COVID-19 patients, categorized by disease severity. We also compared patients with severe COVID-19 to a control group with other severe, non-COVID-related diseases. Our findings indicate that the severity of COVID-19 corresponds to the overall production of specific autoantibodies, which are particularly associated with COVID-19. This association might predispose to an increased risk for the development of autoimmune conditions after a severe course of COVID-19.