Neurologic complications are common in patients with sepsis and are associated with worse outcomes, increased length of stay, and long-term disability. This review outlines the major neurologic syndromes encountered in the context of sepsis, including sepsis-associated encephalopathy (SAE), seizures, cerebrovascular events, and ICU-acquired weakness due to critical illness polyneuropathy and critical illness myopathy. We take a pragmatic, bedside-oriented approach to guide clinicians in evaluating septic patients with neurologic symptoms, most commonly presenting with altered mental status. We highlight diagnostic challenges when sedation, metabolic abnormalities, or medications confound the neurologic examination. Beginning with the clinical presentation and neurological examination, we review diagnostic pathways involving neuroimaging, continuous electroencephalogram (EEG), and laboratory studies to differentiate SAE from other neurologic conditions that may require specific treatment. Each neurologic complication is explored in detail, with emphasis on key exam findings, diagnostic strategies, and management principles. We also discuss the evolving understanding of central nervous system involvement in sepsis, including blood-brain barrier disruption, neuroinflammation, and microvascular injury as well as the long-term neurologic consequences of sepsis, including post-sepsis syndrome, cognitive impairment, increased risk of epilepsy, and increased stroke risk. Neurological complications are frequent, clinically important, and often underrecognized in sepsis. By providing a structured, practical framework, this review supports early recognition, informed evaluation, and individualized management of neurologic complications in sepsis while also emphasizing the long-term impact of brain health.

BackgroundPatients with sepsis-associated liver injury (SALI) are at marked risk of delirium, a severe complication strongly linked with poor neurological outcomes. Early identification remains challenging, as existing predictive tools lack specificity for this distinct population. An interpretable machine learning (ML) model was designed and validated to enable prediction of delirium among SALI patients.MethodsDe-identified data from MIMIC-IV were retrospectively assessed in this cohort study. The dataset was randomly partitioned, with 70% assigned to model training and 30% reserved for evaluation. Independent predictors were identified through univariate analysis followed by stepwise multivariable logistic regression. Support Vector Machine (SVM), Logistic Regression (LR), Random Forest (RF), Gradient Boosting Machine (GBM), and Extreme Gradient Boosting (XGBoost) were constructed and tested regarding discrimination, calibration, and clinical usefulness. Model interpretation was performed using the Shapley Additive Explanations (SHAP) framework.ResultsAmong 1461 patients with SALI, 917 (62.8%) developed delirium. Seven independent risk factors were identified: diabetes with chronic complications, reduced SpO2, decreased hemoglobin, lower Glasgow Coma Scale (GCS) score, and treatment with continuous renal replacement therapy (CRRT), vasopressin, or mechanical ventilation. The GBM model demonstrated optimal performance, achieving an area under the receiver operating characteristic curve (AUROC) of 0.831 in the training set and 0.811 (95% CI: 0.766-0.855) in the testing set. SHAP analysis revealed that mechanical ventilation, GCS score, CRRT requirement, and hemoglobin levels were the most influential predictors, indicating that delirium risk is primarily driven by markers of multi-organ dysfunction.ConclusionsAn interpretable gradient boosting model was established and assessed for its ability to predict delirium among individuals with SALI. The model's transparency, achieved through SHAP analysis, establishes clear associations between delirium and quantifiable markers of multi-organ dysfunction. This tool enables early, individualized risk stratification, facilitating targeted preventive interventions to improve outcomes in this vulnerable population.

BackgroundAcute kidney injury (AKI) is frequent in patients supported with venoarterial extracorporeal membrane oxygenation (VA-ECMO), largely due to the severity of cardiogenic shock and multiorgan failure. Renal replacement therapy (RRT) can be delivered either via an indwelling catheter (parallel system, PS) or through direct connection to the ECMO circuit (integrated system, IS). Their respective safety profiles, particularly regarding infectious, hemorrhagic, and circuit-related complications, remain insufficiently characterized.MethodsWe conducted a single-center retrospective analysis of prospectively collected data from consecutive adults who received RRT for ≥24 h while on VA-ECMO between 2006 and 2019. Complications occurring during the concomitant ECMO-RRT period were compared between IS and PS configurations.ResultsEighty patients (84 procedures: 42 IS, 42 PS) were included. Infectious complications occurred in 31% of IS procedures and 45.2% of PS procedures, with earlier onset in the PS group (3 vs 5 days; p = 0.048). However, in multivariable analysis, IS was not independently associated with reduced infection risk (OR 0.67 [0.27-1.70]; p = 0.421). Hemorrhagic events (54.8% IS vs 59.5% PS) and circuit dysfunctions, including filter clotting, were comparable between groups.ConclusionIn VA-ECMO patients requiring RRT, integrated and parallel configurations demonstrate similar safety profiles with no significant differences in infectious, hemorrhagic, or circuit-related complications. These findings support selecting the RRT configuration based primarily on local expertise and technical feasibility rather than expected differences in complication risk.

BackgroundInfective pneumonia is a major cause of respiratory failure and ICU admission, but non-infectious mimics-such as autoimmune disease, malignancy, and organizing pneumonia-are also common. Multiplex PCR pneumonia panels may help differentiate these entities.MethodsWe conducted a prospective before-and-after study (1 Jan 2024-30 Jun 2025) evaluating the FilmArray Pneumonia plus panel (FAPN) in adults with respiratory failure admitted to two district general hospital ICUs. Consecutive patients undergoing FAPN testing (n = 116) were included. In the post-intervention cohort (n = 56), a consensus panel determined the cause of respiratory failure in patients with suspected pneumonia (PF ratio <300 mm Hg and ≥1 radiographic quadrant involvement). Agreement between FAPN and sputum culture-including the diagnostic value of a negative FAPN-was assessed.ResultsAmong post-intervention patients with suspected pneumonia (n = 45), the combined finding of "negative FAPN and negative sputum culture" identified non-infectious mimics with a sensitivity of 75% (95% CI 50-100%) and specificity of 91% (95% CI 81-100%). In multivariable analysis, negative FAPN results were associated with reduced antibiotic escalation (OR 0.70; p < .01). The positive predictive value of individual FAPN bacterial targets ranged from 0%-100% (median 35%). Culture confirmation increased with higher FAPN quantitative bins: 8% at 104 CFU/mL, 7% at 105 CFU/mL, 48% at 106 CFU/mL, and 57% at 107 CFU/mL.ConclusionsIn ICU patients with suspected pneumonia, a combined negative FAPN and sputum culture result should prompt evaluation for non-infectious mimics. Negative FAPN findings may help reduce unnecessary antibiotic escalation, although their positive predictive value for culture-confirmed bacterial infection is limited.

PurposeSerratia marcescens is a well-recognized hospital-acquired pathogen frequently implicated in outbreaks in neonatal and pediatric intensive care units. We compared clinical characteristics of infants with Serratia bloodstream infections (BSI) to those with non-Serratia gram-negative BSI.MethodsA retrospective case-control study comparing infants (0-2 y/o) hospitalized at our referral pediatric cardiac intensive care unit (PCICU), who acquired gram-negative blood cultures, during 2012-2022. Patients were categorized into two groups: S. marcescens BSI versus non-Serratia gram-negative BSI. Demographic and clinical data were extracted from our medical databases.ResultsOf 112 patients meeting inclusion criteria, 40 (36%) had Serratia BSI and 72 (64%) non-Serratia gram-negative BSI. Blood stream infection with Serratia occurred later postoperatively (median 15 vs 7 days, p < .01), were associated with less pre-infection inotropic support (median VIS 0 vs 5, p < .01) and higher rates of multisite involvement (35% vs 18%, p = .04). Duration of indwelling vascular catheters at time of infection was longer in the Serratia group (median 10 vs 7 days, p = .03). No associated mortality was attributed to Serratia BSI, as compared to a 5.6% mortality rate in the non-Serratia group.ConclusionsSerratia BSI in the PCICU tends to develop later during hospitalization, involves more multiple infection sites, and is associated with longer vascular catheters dwell durations at the time of infection. Serratia infections appeared sporadically throughout the year without seasonal clustering. This supports the importance of stringent infection control practices and warrants prospective studies on prevention strategies.

Impaired GI tract function is a common and often underappreciated symptom in the Medical Intensive Care Unit (MICU). The most visible manifestation of this dysfunction is reduced bowel movements. The occurrence of impaired GI function is associated, both independently and in association with delayed enteral feeding, with increased length of stay, morbidity and mortality. We report on a process implementation project conducted at a single academic center designed to: (I) increase visibility of bowel movement charting and (II) transition from a reactive to a proactive laxative administration regimen for prophylaxis against MICU associated constipation. Scheduled laxatives, polyethylene glycol and sennoside-docusate, were added to the MICU admission orderset and bowel movement charting was moved to a more readily accessible flowsheet in the electronic medical record. Six months of pre-intervention and post-intervention admissions to the MICU were reviewed to determine patient demographics, admitting diagnosis, Sequential Organ Failure Assessment (SOFA) score, laxative utilization, and time to first bowel movement. Following implementation of these changes, prophylactic laxative utilization significantly increased (p < .001) driven largely by the agents included in the orderset. This was associated with a decrease in MICU length of stay by an average of 21 h (p = .006) and median time to first bowel movement by 4 h (p = .026), but no changes in incidence of impaired transit (as defined by greater than 72 h without a bowel movement). This data represents an exciting first step in the use of mixed agent prophylactic laxative regimens.

Pulmonary hypertension, defined as an elevation of the mean pulmonary artery pressure above 20 mm Hg, is an increasingly common diagnosis in patients admitted to the intensive care unit either as a primary pathology or as the result of other medical conditions. Proper assessment to identify the contributing factors and identify key specific etiologies is essential to properly manage these patients and improve patient outcomes. A subset of patients with causes of pulmonary hypertension such as Group 1 pulmonary arterial hypertension or Group 4 chronic thromboembolic pulmonary hypertension require specific treatments that deviate from usual intensive unit care and are critical to patients' survival. These patients and patients with advanced pulmonary hypertension from other causes may benefit from specialized treatments targeting the right ventricle and pulmonary circulation complex, and warrant transfer to a center with pulmonary hypertension expertise. This review will discuss pulmonary hypertension epidemiology, physiology of the right ventricle and pulmonary circulation complex, stepwise diagnosis and classification of patients, management of cardiorespiratory support medications and devices, perioperative considerations, and special populations such as transplant candidates and pregnancy.

PurposeTo characterize post-intensive care syndrome (PICS) in critical patients who survived COVID-19 during the first pandemic wave and to follow PICS symptoms during one year.Material and methodsProspective, observational, multicenter cohort study conducted in 11 Spanish ICUs. Critically ill adult patients who survived SARS-CoV-2 infection and met risk criteria for PICS were included. In-person follow-up was conducted at 3, 6, and 12 months after hospital discharge, assessing physical, cognitive, psychological, and nutritional aspects, quality of life and return to daily activities.ResultsA total of 227 patients were included, of which 120 (52.9%) completed the 3 follow-up visits. Hand dynamometry showed muscle weakness in 40.9% of patients at 3 months, with improvement over time. Anxiety, depression, post-traumatic stress disorder (PTSD) and cognitive impairment were observed in 32.9%, 24.3%, 13.8% and 46.1% of patients, respectively, at 3 months. While anxiety, depression and cognitive impairment slightly decreased over time, PTSD did not. Nutritional risk was significant at 3 months (42.4%), with gradually recovering (3.9% at 1 year). Patients' autonomy, and perception of physical and mental quality of life, improved over the months. At 3 months, 35% of patients had returned to work, and 58.3% at one year. A significant percentage of patients required assistance from physical therapy and mental health professionals after discharge.ConclusionSignificant impairment was observed in all areas of PICS in critically ill patients with COVID-19, with progressive improvement over one year of follow-up, with the adoption of physical, mental, cognitive, and nutritional support measures.

Acute variceal bleeding (AVB) is a known complication of decompensated cirrhosis and carries with it a high mortality rate. Understanding the basic underlying pathophysiologic processes that lead to the development of varices and how to prevent progression of this disease is crucial for an intensivist. Once bleeding occurs, intensivists must be able to navigate a complex presentation of impending respiratory failure and hemorrhagic shock. A multidisciplinary approach to AVB including medical therapies combined with procedural interventions such as endoscopy, balloon tamponade, and emergency surgery must all be considered in severe cases. In this narrative review, we aim to provide an updated and comprehensive overview of the prevention and management of variceal bleeding in patients with cirrhosis.

PurposePrevious studies evaluating clonidine for dexmedetomidine weaning in critically ill patients have shown efficacy but are limited to smaller samples of adult or pediatric patients. The objective of this study was to evaluate the efficacy and safety of enteral clonidine in the transition from dexmedetomidine for agitation and sedation in the intensive care unit (ICU).Materials and MethodsThis was a single-center, retrospective cohort study of adult patients admitted to an ICU at UMass Memorial Medical Center between May 1, 2022 to April 30, 2023 who received enteral clonidine for the indication of weaning dexmedetomidine. The primary outcome was discontinuation of dexmedetomidine within 24 h of starting enteral clonidine. A priori risk factors for the primary outcome included duration of dexmedetomidine prior to clonidine initiation, clonidine total daily dose, average Richmond Agitation-Sedation Scale (RASS) and Sequential Organ Failure Assessment (SOFA) scores, history of a psychiatric disorder, intubation at time of clonidine initiation, and being on additional sedation agents at the time of clonidine initiation. Safety outcomes included the incidence of bradycardia, hypotension, and withdrawal.ResultsSeventy-three patients were included. The primary outcome of dexmedetomidine discontinuation within 24 h occurred in 38 patients (52%). Multivariable logistic regression analysis of the a priori risk factors indicated that non-intubated patients at the time of clonidine initiation were significantly more likely to achieve the primary outcome (OR 4.27, 95% CI 1.04-17.62, p = 0.04). Incidence of bradycardia (5% clonidine vs 16% dexmedetomidine, p = 0.04) and withdrawal (0% vs 49%, p < 0.0001) were higher while patients were on dexmedetomidine.ConclusionsClonidine was efficacious in weaning dexmedetomidine within 24 h in 52% of patients; however, the ideal dose and period for initiation remains unclear. Results of this study warrant further investigation to identify optimal clonidine dosing for dexmedetomidine weaning and to characterize patient populations that would benefit most from this intervention.