Intensive Care Foundation

Pregnancy in women with cardiovascular disease (CVD) represents a distinct clinical condition, as the physiological adaptations of pregnancy may interact with underlying cardiac pathology in variable and sometimes unpredictable ways. Consequently, maternal and foetal risk cannot be assumed a priori and requires structured, patient- and disease-specific assessment. The new ESC guidelines on cardiovascular disease and pregnancy incorporate updated evidence following the 2018 version. The contents span from models of multidisciplinary care (the Pregnancy Heart Team, PHT), pre-pregnancy counselling, and pregnancy-related risk assessment, to novel recommendations that are both shared by all pregnancies in women with CVD and specific to each distinct disease. Due to limited prospective or randomized studies largely prevented by ethical reasons, most recommendations are based on evidence level C. This document provides a concise synthesis of innovations in shared management strategies and disease-specific pathways in pregnancy of women with known CVD. It also acknowledges that not all clinical scenarios can be fully captured by guideline-based recommendations. Beyond guidelines, and primarily because approximately 50% of recommendations are Level C evidence, there is considerable decision-making margin for cardiovascular specialists to adhere recommendations. For rare unpredictable complications/events the limited available evidence does not allow recommendations to be made. Looking to the future, the expectation is that AI, which is already generating data and models of care in pregnancy, can help support widespread access to PHT, both in hospitals equipped with the necessary requirements and remotely to all healthcare facilities serving pregnant women with CVDs.

Recent studies have shown a potential neuroprotective role of dexmedetomidine in subarachnoid hemorrhage. However, its effect on neurological outcomes and optimal dosing regimen remains unclear. We randomized 75 adults with good grade aneurysmal subarachnoid hemorrhage undergoing clipping to receive dexmedetomidine, low-dose (Group D1,0.2μgkg-1h-1, n = 25), standard dose (Group D2, 0.5μgkg-1h-1, n = 25), or normal saline (Group C, n = 25) commenced postinduction of anesthesia and continued for 24 hours. Our primary objective was to assess rates of good functional outcome, defined as a modified Rankin Scale (mRS) Score of 0 to 2, at hospital discharge. Secondary outcomes included rates of good functional outcome at 3 months, levels of blood lactate, S100β, and Neuron Specific Enolase (NSE), incidence of vasospasm, delayed cerebral ischemia (DCI), and cerebral dysautoregulation. Neurological outcome at discharge was better in Group D1 as compared to Group C (mRS 0 to 2, Group D1 vs. C; 19 (76%) vs. 9 (36%), P = 0.02), while it was similar in Group D2 as compared to D1 and C. Neurological outcome at 3 months was comparable among the 3 groups. The lactate levels were significantly lower in Group D1 as compared to Groups D2 and C at 12 and 24 hours. The levels of NSE and S100β were significantly lower in D1 and D2 as compared to Group C. Other measured parameters were comparable. Low-dose dexmedetomidine was associated with a favourable neurological outcome at discharge compared to the control group. Larger trials are necessary to conclusively establish the neuroprotective effect of dexmedetomidine.

Although videolaryngoscopy is particularly helpful in patients with limited mouth opening, a severely restricted mouth opening is its hardest limitation. This analysis aimed to explore critical lower limits for interincisor distances that optimally predict (i) difficult Macintosh videolaryngoscopy or (ii) the risk of Macintosh videolaryngoscopy failure and may warrant consideration of alternative or awake techniques. This analysis from a prospective observational study includes 192 adults at increased risk for difficult Macintosh videolaryngoscopy undergoing head and neck surgery managed with Macintosh videolaryngoscopy (C-MAC) as the first-choice technique. Interincisor distances were measured before and after anesthesia induction. Five clinical indicators (outcome measures) for difficult Macintosh videolaryngoscopy (multiple attempts, conversion to hyperangulated videolaryngoscopy, documentation of a difficult videolaryngoscopic intubation, hyperangulated videolaryngoscopy recommended for future anesthesia, anesthesia alert card issued) and 2 key indicators for the risk of Macintosh videolaryngoscopy failure (vocal cords not visible, awake flexible endoscopy recommended for future anesthesia) were systematically assessed. Mouth opening was grouped in 2 mm intervals; the Youden index was calculated for each of these intervals and the maximum Youden index (Jmax) was noted for each of the 7 indicator. For each mouth opening interval, the deviation from this maximum Youden index (Jd-max) and the mean Jd-max across all indicators were calculated to identify optimal thresholds. The incidence of difficult videolaryngoscopic intubation was 56.8% (109/192). Optimal discrimination between easy and difficult Macintosh videolaryngoscopy (best mean Jd-max values) was derived from interincisor distances between 23 and 35 mm. The incidence of failed Macintosh videolaryngoscopy was 26.0% (50/192) in our study cohort and showed a clear inverse correlation with the interincisor distance. Discrimination between low and high risk of Macintosh videolaryngoscopy failure was optimal (best mean Jd-max values) between 21 and 23 mm. After anesthesia induction, interincisor distances increased in 31.8% (61/192), remained unchanged in 17.2% (33/192) but decreased in 51.0% (98/192) of the patients. The highest risk of reduction was found in individuals with degenerative cervical joint diseases (odds ratio [OR] = 6.43 [1.27-32.5]; P = .02), the lowest in those with facial fractures (OR = 0.27 [0.08-0.92]; P = .04) compared with a reference category. Our findings suggest that among individuals with expected difficult airway management, interincisor distances below 21 to 23 mm indicate increased risk of Macintosh videolaryngoscopy failure and may warrant alternative or awake techniques. Caution should be exercised as the mouth opening frequently decreases after anesthesia induction. Results should not be extrapolated to routine intubations in noncomplex patients.

Background: Cardiac implantable electronic devices (CIEDs) are vital for managing arrhythmias but carry a notable risk of infection, which increases patient morbidity, mortality, and healthcare burden. This review examines current evidence on risk factors and preventive strategies for CIEDI. Methods: A structured search was performed in PubMed, Embase, and the Cochrane Library using terms such as “CIED,” “infection,” “pacemaker,” “ICD,” “infection prevention,” “biofilm,” “antibiotic prophylaxis,” and “antibiotic-eluting envelope.” Study selection followed PRISMA guidelines. Results: For well-established topics, recommendations are based on high-quality evidence from the literature. In areas with limited CIED-specific data, evidence from related surgical fields was considered, and expert consensus was used to guide recommendations. Conclusions: This review offers practical guidance for clinicians on CIED infection prevention, addressing gaps not previously covered in existing guidelines.

IssueMass gatherings challenge healthcare systems, requiring structured preparedness to prevent hospital congestion. The 2024 Alpini National Gathering, held in Vicenza, Italy (May 10-12, 2024), drew 400,000 attendees, tripling the city's population. Without a coordinated strategy, emergency services could have been overwhelmed. ULSS 8 Berica, the local health authority, implemented a healthcare plan, ensuring seamless coordination between pre-hospital and hospital services, with San Bortolo Hospital as the main referral center.DescriptionA structured healthcare strategy was activated to optimize patient management and hospital resources. Key components: 1. Four Advanced Medical Posts (PMA) to treat minor cases on-site, reducing ED visits; 2. A Temporary Field Hospital to stabilize moderate cases and limit hospital transfers; 3. Hospital capacity optimization, reinforcing staff and triage protocols; 4. Real-time coordination with SUEM 118 for efficient ambulance dispatch and referrals.Results- San Bortolo Hospital recorded 714 ED visits, a 7-11% decrease from the previous week. 94 hospitalizations remained stable despite the population surge. - The Field Hospital treated 106 patients, with only 7 requiring hospitalization, reducing hospital burden. Four PMAs handled 52 minor cases, filtering non-critical patients from the ED. - SUEM 118 handled 3074 emergency calls, 787 event-related, with 226 SAP on-site interventions, optimizing resources. - The triage system led to a 20% reduction in hospital admissions, based on pre-event trends, demonstrating the effectiveness of decentralized care.Lessons- Pre-hospital triage reduced hospital congestion while maintaining care quality. - Shuttle services and designated routes ensured timely workforce deployment. - This scalable model strengthens public health preparedness for future mass gatherings.Key messages• A coordinated mass gathering healthcare strategy prevented hospital overload and optimized emergency response.• Integrating pre-hospital and hospital services enhanced system resilience and ensured continuity of care during large-scale events.

Purpose of reviewRoutine diagnostic tests for childhood pneumonia lack the accuracy to identify bacterial pneumonia, leading to inappropriate antibiotic prescription. Novel tests are being developed. Optimizing diagnostic strategies using available diagnostic tools and exploring the role of new tests is essential to improve antimicrobial stewardship (AMS) in children. This review provides an overview of advances in diagnostic testing for pediatric pneumonia and discusses how strategies can be optimized in different settings in order to improve AMS.Recent findingsAll currently available tests for bacterial pneumonia are limited in their diagnostic accuracy. However, in settings with high baseline antibiotic prescription, routine diagnostics such as CRP or PCT-guided prescription can improve antibiotic use. Among the innovative tests, lung ultrasound with computer-aided detection and prediction models combining multiple tests holds most promise for low-resource settings. For high-resource settings, RNA signatures and next-generation sequencing are promising developments. The impact of innovative tests on AMS remains to be evaluated.SummaryRobust diagnostic and contextual research is needed to develop new diagnostic tests and to optimize current strategies for bacterial pneumonia in children. In order to tailor diagnostic approaches to specific settings, broad impact studies and stratification of risk groups are crucial.

We aimed to evaluate the prognostic role of baseline and 24-hour plasma lactates in patients with cardiogenic shock (CS). Multicenter, observational, prospective Altshock-2 Registry (NCT04295252) enrolling patients with CS since March 2020. Multicenter Italian Registry (12 centers). Six hundred fifty-one consecutive patients with CS and available data on lactate values. None. The association of baseline and 24-hour lactates with in-hospital mortality (primary endpoint) was evaluated. The optimal lactate cutoff points for predicting outcomes were identified in the overall cohort and among patients treated with mechanical circulatory support (MCS). Among the 651 included patients with CS, the mean age was 64 ± 14 years and 76% were male. On admission, patients with lactates less than 2.0, 2.1-4.0, and greater than 4.0 mmol/L were 248 (38.1%), 172 (26.4%), and 231 (35.5%), respectively. An improvement in lactate values at 24 hours was observed in 76.5% of patients. Baseline and 24-hour lactates were both independently associated with increased mortality (adjusted odds ratios for each 1-mmol/L increase: 1.08 [95% CI, 1.02-1.14] for baseline lactate; and 1.37 [95% CI, 1.15-1.63] for 24-hr lactate), but 24-hour lactates had a higher predictive accuracy than baseline lactates (area under the curve 0.702 vs. 0.648). The optimal baseline and 24-hour lactate cutoffs for predicting mortality were 3.2 mmol/L and 1.7 mmol/L, respectively, and varied in patients treated with MCS at different time points. Higher baseline and 24-hour lactates were both independently associated with increased in-hospital mortality in patients with CS, although the 24-hour value had a higher predictive accuracy. Optimal lactate cutoffs for predicting mortality varied between admission and 24 hours and according to the MCS strategies.

We aimed to assess the impact of pre-admission beta-blocker (BB) therapy on the clinical characteristics, in-hospital treatment and outcomes of patients with cardiogenic shock (CS). All patients enrolled in the multicentre prospective Altshock-2 registry since March 2020 with available data on pre-admission BB therapy were included. Clinical characteristics, in-hospital management, haemodynamic parameters and clinical outcomes were compared in patients with versus without BB therapy. The primary endpoint was in-hospital mortality. A total of 668 patients were included [median age 66 (56-74) years, male sex 76.5%]: 299 patients (44.8%) with and 369 patients (55.2%) without previous BB therapy. Patients receiving pre-admission BB therapy had more frequently heart failure-related CS (43.8% vs. 17.9%) and less frequently cardiac arrest at presentation (20.1% vs. 27.8%, P=0.027). Levosimendan was used less frequently and dobutamine was used more frequently in patients with baseline BB therapy (P=0.033 and P=0.043, respectively). Differences in the early haemodynamic response to vasoactive drugs were observed between patients with and without previous BB therapy, with a significant impact of baseline BB on mean arterial pressure (MAP) response during norepinephrine infusion (P=0.012) and with dobutamine having a reduced response in MAP and heart rate in patients receiving BBs before admission (P=0.023 and P=0.001, respectively). In-hospital mortality was not significantly different between the BB and no-BB groups (40% vs. 33.7%; adjusted odds ratio 1.32, 95% confidence interval 0.84-2.07, P=0.224). Similarly, baseline BB therapy was not independently associated with 48h mortality (12.7% vs. 14.6%; adjusted odds ratio 1.09, 95% confidence interval 0.64-1.87, P=0.749). The lack of association between baseline BB therapy and mortality was also confirmed at inverse probability of treatment weighting-adjusted analysis. In a real-world, contemporary cohort of patients with CS, previous BB therapy influenced the haemodynamic response to vasoactive drugs, but it was not associated with in-hospital mortality.

Total hip arthroplasty (THA) is an effective treatment for end-stage hip disorders, improving pain, function, and quality of life. For bilateral hip disease, choosing between one-stage (simultaneous) and two-stage (staged) bilateral THA is critical. One-stage THA may reduce hospitalization but carries higher risks. This study evaluates whether one-stage bilateral THA is non-inferior to two-stage THA in safety and functional recovery. A retrospective study of patients undergoing bilateral THA between January 2010 and November 2019 compared one-stage (84 patients) and two-stage (63 patients) procedures. Surgeries used a postero-lateral approach with H-Max and DeltaTT implants. Outcomes included pain (VAS), function (Oxford Hip Score, EQ-5D, Forgotten Joint Score), and complications. Follow-ups were conducted at 1, 3, and 6 months, and at 5 years for both groups. Both groups showed significant improvements in pain and function scores with no differences between them. Forgotten Joint Score was also comparable. Complications, including urinary infections and hematomas, were similar, and no revisions occurred in the one-stage group, compared to a 1.6% revision rate in the two-stage group. Hemoglobin decrease and transfusion rates were comparable. Both approaches resulted in improved symptoms and quality of life with similar complication rates. The one-stage group had fewer complications and no revisions, suggesting potential cost savings. These findings support the safety of one-stage bilateral THA, emphasizing the need for careful patient selection and surgical expertise.