Clinical Critical Care

Fluid de-escalation therapy in critically ill patients: A comprehensive review

2025-07-22T10:10:44+07:00

Fluid overload is a common complication following fluid therapy in patients with circulatory shock, and fluid de-escalation therapy plays a vital role in preventing this condition. This article aims to explore the management of fluid de-escalation across different phases, highlights the appropriate timing for its implementation, and discusses the roles of diuretics and mechanical fluid removal. Practical strategies for monitoring are also explored.

Phenotype-specific insulin strategies in shock states: A critical reappraisal

2026-02-19T12:57:32+07:00

The use of insulin in critical care involves three distinct strategies: Intensive Insulin Therapy (IIT), High-Dose Insulin (HDI), and Glucose-Insulin-Potassium (GIK). This review clarifies their indications, mechanisms, and safety profiles. IIT primarily targets stress-induced hyperglycemia in sepsis; however, current guidelines recommend a moderate target (140–180 mg/dL) to avoid hypoglycemia, functioning as a supportive measure without direct mortality benefit. HDI serves as a potent inotropic antidote for refractory calcium channel blocker and beta-blocker poisoning. Its safe use requires concentrated dextrose to prevent fluid overload and strict "permissive hypokalemia" management. GIK is an investigational "metabolic resuscitation" therapy aimed at recruiting hibernating myocardium in septic cardiomyopathy. While potentially beneficial for hypodynamic states, GIK poses a significant risk of severe hypotension in vasoplegic patients due to insulin's vasodilatory effects. Matching the correct insulin strategy to the patient's specific hemodynamic phenotype is critical to maximize efficacy and prevent life-threatening complications.

Safe titration of pressure-support ventilation: Balancing patient effort, drive, and ventilator assistance

2026-02-06T15:14:54+07:00

Pressure-support ventilation (PSV) is commonly used for invasive weaning and assisted ventilation. However, bedside titration often relies on tidal volume and rate rather than direct indices of respiratory drive and inspiratory effort, risking over- or under-assistance with downstream diaphragm dysfunction, asynchrony, and lung stress. This narrative review synthesized a physiology-guided approach to safe PSV titration and proposed practical bedside guidance for intensivists adjusting trigger sensitivity, rise time, pressure-support level, and cycling to maintain synchrony while targeting a moderate, sustainable patient effort. Practical monitoring included airway pressure-based measures, including airway occlusion pressure at 100 ms (P0.1), end-expiratory occlusion pressure (Pocc), and the pressure muscle index (PMI), as well as esophageal manometry, diaphragm electrical activity (EAdi), and diaphragm ultrasound thickening fraction (TFdi). Integrating these tools promotes an “adequate assistance” zone in which tidal volume (VT) and respiratory rate remain stable across modest PS changes and effort is neither suppressed nor excessive. Proportional modes, such as neurally adjusted ventilatory assist (NAVA) and proportional assist ventilation plus (PAV+), can enhance interaction by scaling support to immediate effort, but physiology-based assessment remains central to individualized, lung- and diaphragm-protective ventilation during PSV.

Tranexamic acid in hemostasis and resuscitation: A comprehensive clinical review

2025-12-31T08:08:28+07:00

Tranexamic acid (TXA), a synthetic lysine analogue that stabilizes fibrin clots against premature degradation, has become a cornerstone in the management of acute hemorrhage. Its application has expanded from well-established indications like trauma and postpartum hemorrhage to a variety of other clinical scenarios. However, this widespread use is accompanied by a complex evidence base, with significant variations in dosing, timing, and administration routes, and a growing recognition of conditions where TXA's risk may outweigh its benefit. This narrative review aims to consolidate and critically appraise the evidence from landmark clinical trials and major international guidelines. We explore the established and emerging indications for TXA, delve into its nuanced safety profile, and highlight the critical importance of timely administration. Ultimately, this review provides clinicians with a practical, evidence-based synthesis to guide the safe and effective use of TXA in resuscitation and the management of bleeding.

Understanding drug-induced hyperthermia

2026-01-07T09:06:11+07:00

Drug-induced hyperthermia encompasses a spectrum of potentially life-threatening syndromes caused by pharmacological agents. This review summarizes the current understanding about the disease pathophysiology, clinical manifestations, diagnostic challenges, and therapeutic strategies. Emphasis is placed on major syndromes, including neuroleptic malignant syndrome, serotonin syndrome, malignant hyperthermia, anticholinergic toxicity, and sympathomimetic toxicity. Early recognition and timely intervention are crucial for reducing morbidity and mortality.

Venous congestion in surgical patients assessed by the Venous Excess Ultrasound Grading System (VExUS): A comprehensive review

2025-12-30T17:48:20+07:00

Venous congestion from fluid overload is an underrecognized contributor to postoperative organ dysfunction. The Venous Excess Ultrasound Grading System (VExUS) is a non-invasive Doppler-based tool for assessing systemic venous congestion at the bedside. This review outlines the physiological basis, step-by-step protocol, and current clinical evidence for VExUS use in surgical patients. While it shows potential for guiding fluid management, results across studies are mixed, and several clinical limitations affect interpretation. VExUS is feasible and promising, but further multicenter research is needed to establish its clinical value and integration into perioperative care.

Fentanyl-induced rigid chest syndrome after low-dose fentanyl: A case report

2026-03-16T10:29:18+07:00

Background: Fentanyl-induced rigid chest syndrome (FIRCS) is a rare, life-threatening adverse effect of fentanyl that can cause respiratory compromise and patient-ventilator dyssynchrony and currently lacks definitive diagnostic criteria.

Case presentation: A 73-year-old Thai female with hepatitis C-related cirrhosis was admitted to the intensive care unit with septic shock and acute respiratory failure due to community-acquired multilobar pneumonia. She was intubated and mechanically ventilated in pressure-controlled mode. After receiving a fentanyl bolus of 50 mcg followed by a continuous infusion of 50 mcg/hour, she developed progressive patient-ventilator dyssynchrony with low tidal volume and worsening hypercapnia despite ventilator adjustments. Physical examination revealed a diffuse rigid abdominal wall. Ventilator flow-time waveforms suggested markedly reduced respiratory compliance. FIRCS was suspected. After discontinuation of fentanyl, incremental intravenous naloxone was administered. A total dose of 0.2 mg resulted in rapid improvement in tidal volume, minute ventilation, and ventilator waveform patterns within one minute. Recurrent symptoms occurred one hour later and resolved after an additional naloxone dose.

Conclusions: FIRCS can occur even with relatively low-dose fentanyl infusion. Recognition of characteristic ventilator waveform patterns is helpful in early diagnosis and prompt treatment.

Refractory hypotension in amyloidosis patient: A case report

2025-12-23T20:49:33+07:00

Background: shock is a critical condition resulting from circulatory failure and is commonly observed in intensive care settings. It arises from four primary mechanisms, including hypovolemic, cardiogenic, distributive, and obstructive shock. However, some cases lack an identifiable cause or present with conditions mimicking sepsis. Rare causes, such as autonomic dysfunction, manifest through cardiovascular abnormalities like orthostatic hypotension and abnormal vasovagal responses. We reported here a case of autonomic dysfunction with amyloidosis due to its uncommon nature and significant influence on mortality rates. Timely and precise diagnosis, coupled with effective treatment, has the potential to be life-saving for the patient.

Case presentation: A 73-year-old female with a past medical history of curative breast cancer 15 years ago, sick sinus syndrome status post DDDR 3 years ago, and previous heart failure with an unremarkable coronary angiography result, presented for evaluation of progressive dysphagia. Following admission for esophagogastroduodenoscopy, she developed clinical symptoms consistent with septic shock and acute kidney injury with volume overload, which resolved after appropriate treatment. Subsequently, the patient experienced unexplained hypotension accompanied by periorbital ecchymosis, prompting a skin biopsy, serum protein electrophoresis, and free light chain testing, ultimately leading to a diagnosis of AL amyloidosis. After discussing the treatment plan, the patient opted for palliative care, and pharmacotherapy was provided as part of supportive management.

Conclusion: Refractory hypotension in AL amyloidosis poses a multifaceted clinical challenge, requiring a thorough and individualized treatment approach that considers the unique circumstances and therapeutic requirements of each patient.

Thrombocytopenia-associated multi-organ failure after Fontan operation successfully treated with plasma exchange: A case report

2025-11-06T17:25:54+07:00

Introduction: Thrombocytopenia-associated multi-organ failure (TAMOF) is a rare but life-threatening subtype of multiple organ dysfunction syndrome caused by thrombotic microangiopathy and decreased A Disintegrin and Metalloproteinase with a Thrombospondin type 1 motif, member 13 (ADAMTS-13) activity. Although commonly associated with sepsis, TAMOF is rarely reported after cardiac surgery.

Case Presentation: We report a 10-year-old girl with right atrial isomerism and complex congenital heart disease who developed TAMOF following extracardiac Fontan surgery. She presented with distributive shock, persistent thrombocytopenia, acute kidney injury requiring continuous renal replacement therapy, transaminitis, and encephalopathy. Laboratory findings demonstrated thrombotic microangiopathy with elevated inflammatory markers. Plasma exchange (PLEX) was initiated based on clinical suspicion and later confirmed by reduced ADAMTS-13 activity. After two PLEX sessions, the patient showed rapid improvement, including platelet recovery, resolution of neurological, hepatic, and renal dysfunction, and successful extubation.

Conclusions: Early recognition of TAMOF in post-cardiac surgery patients with unexplained thrombocytopenia and multi-organ dysfunction is critical. Prompt PLEX may result in clinical recovery and improved survival.

Nutritional status of mechanically ventilated critically ill patients in a university-based hospital in Northern Thailand

2026-02-03T10:25:06+07:00

Background: Malnutrition is common in mechanically ventilated critically ill patients and contributes to poor outcomes. This study evaluated its prevalence and associated factors in a medical critical care unit (MCCU).

Method: A retrospective study of adult mechanically ventilated patients admitted between May 2021 and July 2024. Nutritional status was assessed using NT 2013, with day-7 status used for outcome analysis. Logistic regression identified factors associated with malnutrition.

Result: Among 334 patients, malnutrition prevalence was 36.8% at admission and increased to 44.3% during hospitalization. Malnourished patients had lower BMI and higher severity scores (APACHE II, SAPS II, SOFA). They also experienced worse outcomes, including higher MCCU mortality (26.0% vs. 14.8%), higher in-hospital mortality (41.5% vs. 25.4%), longer mechanical ventilation, and longer hospital stays. These associations persisted in patients hospitalized ≥7 days. Independent factors associated with malnutrition were younger age (aOR 0.97) and higher APACHE II score (aOR 1.07).

Conclusion: Malnutrition is frequent and worsens during MCCU stay, and is linked to poorer clinical outcomes. Early assessment, close monitoring, and timely individualized nutritional support are essential.

Critical care management in military warfare and blast-induced neurotrauma: Lessons from the Thai–Cambodian border conflict

2026-01-30T11:35:56+07:00

Background: To describe the organization, delivery, and outcomes of critical care for combat casualties and blast-induced neurotrauma during active hostilities along the Thai–Cambodian border, with emphasis on operational strategies applicable to high-risk environments.

Method: This retrospective observational operational report reviews casualty management at Prasat Field Hospital between 24 July and 1 August 2025. Clinical data were obtained from hospital records, ICU logs, surgical reports, and Emergency Operations Center (EOC) documentation. All military and civilian casualties presenting alive during the study period were included.

Result: A total of 144 casualties were treated, including 32 patients requiring intensive care. Thirteen patients underwent emergent surgical intervention for severe injuries, including intracranial hemorrhage, major vascular trauma, airway disruption, and complex polytrauma. Integrated damage-control surgery, forward critical care capability, and coordinated MEDEVAC resulted in zero in-hospital mortality among patients who reached definitive care.

Conclusion: Effective critical care in conflict settings depends on forward deployment of ICU capability, structured triage, multidisciplinary coordination, and rapid evacuation pathways. Blast-induced neurotrauma requires early recognition, prevention of secondary injury, and sustained neurocritical care. Experience from the Thai–Cambodian border conflict highlights the evolving role of field hospitals as integrated trauma–critical care centers in modern warfare.

Trial registration: TCTR20240828001

Dynamic arterial elastance for predicting mean arterial pressure response to fluid administration in hypotensive critically ill surgical patients: Prospective observational study

2025-12-23T21:05:09+07:00

Background: Postoperative hypotension frequently occurs in high-risk surgical patients and is associated with elevated risks of adverse cardiovascular outcomes. Dynamic arterial elastance (Ea_dyn), calculated as the ratio of pulse pressure variation (PPV) to stroke volume variation (SVV), has been proposed as a functional parameter to guide fluid resuscitation by reflecting arterial load.

Method: This prospective observational study was conducted in a single tertiary care center and enrolled postoperative patients who developed hypotension requiring fluid resuscitation. Hemodynamic variables were measured immediately before and after fluid administration. PPV was recorded through an invasive arterial catheter, while SVV was assessed using an internally calibrated pulse contour analysis device. The primary objective was to determine Ea_dyn’s predictive performance in predicting mean arterial pressure (MAP) responsiveness following fluid loading. Secondary analyses compared Ea_dyn’s predictive performance with systemic vascular resistance (SVR) and the diastolic shock index (DSI).

Result: Fifty-one patients were included, and 73 hypotensive interventions were analyzed, of which 55 were classified as MAP responders. An Ea_dyn threshold of ≥ 1.02 yielded an area under the receiver operating characteristic curve (AUC) of 0.802 (95% CI, 0.703-0.901), with a sensitivity of 56.4% and a specificity of 100%. In contrast, SVR and DSI demonstrated poor discriminatory ability, with AUCs of 0.548 and 0.565, respectively. Ea_dyn significantly outperformed both indices (p = 0.003).

Conclusion: Ea_dyn is demonstrated as a potential reliable hemodynamic index for predicting MAP responsiveness following fluid administration in mechanically ventilated postoperative patients with fluid-responsive hypotension.

Trial registration: TCTR20240330001

Effects of proton pump inhibitors for stress ulcer prophylaxis in critically ill patients: A randomized control trial

2025-12-23T09:30:03+07:00

Background: Critically ill patients are prone to gastrointestinal bleeding, leading to hemodynamic instability, transfusions, and prolonged hospitalization. Stress ulcer prophylaxis with proton pump inhibitors is commonly used in intensive care, but their benefit is uncertain and may increase hospital-acquired pneumonia risk. This study aimed to evaluate the efficacy and safety of proton pump inhibitors (PPIs) for stress ulcer prophylaxis, focusing on the occurrence of gastrointestinal bleeding and pneumonia.

Method: An open label, randomized controlled trial was conducted at Chiangrai Prachanukroh Hospital between January and October 2022. Critically ill patients were randomly assigned to receive a once-daily dose of omeprazole 40 mg intravenously or without prophylaxis; all received enteral nutrition. The primary outcome was the rate of gastrointestinal bleeding at 30 days, and hospital-acquired pneumonia was a safety outcome.

Results: One hundred thirty patients were enrolled (65 per group). Baseline characteristics, disease severity, laboratory values, and feeding parameters were comparable between groups. The duration of mechanical ventilation was longer in the PPI group, and all patients received enteral nutrition with similar feeding profiles. Gastrointestinal bleeding occurred in 6.15% of patients in the proton pump inhibitor group and 3.08% of controls, with no statistically significant difference. Hospital-acquired pneumonia occurred more frequently in the PPI group than in the control group (23.08% vs. 9.23%) in the crude analysis; however, PPI use was not independently associated with hospital-acquired pneumonia after multivariate adjustment. Mortality was higher in the PPI group (9.23% vs. 1.54%), but the difference was not statistically significant.

Conclusions: Critically ill patients on PPIs have comparable rates of gastrointestinal bleeding. Although the incidence of hospital-acquired pneumonia is higher in the PPI group, the multivariable analysis shows no statistically significant difference.

Trial registration: TCTR20260116007

Tranexamic acid vs. epsilon-aminocaproic acid: Evidence gaps and practical implications

2026-02-27T18:07:10+07:00

Antifibrinolytic agents, particularly tranexamic acid (TXA) and epsilon-aminocaproic acid (EACA), are widely used to reduce perioperative bleeding. Although both drugs share a similar mechanism—competitive inhibition of plasminogen activation—they differ in pharmacologic potency, dosing requirements, and clinical evidence. TXA demonstrates 6–10 times greater affinity for plasminogen, resulting in stronger antifibrinolytic effects at lower doses. Evidence from randomized trials and meta-analyses, primarily in orthopedic surgery, suggests TXA may reduce blood loss more effectively than EACA; however, differences in transfusion rates and thromboembolic complications are generally not significant. In cardiac surgery, limited data show no clear superiority of either agent. TXA has robust evidence supporting its use in trauma and obstetrics, while comparable high-quality data for EACA remain lacking. Both agents appear safe, though high doses—especially in renal impairment—may increase seizure risk. Importantly, EACA may achieve similar clinical outcomes when administered at appropriately higher doses. Current evidence is limited by heterogeneous study designs, variable dosing regimens, and underpowered trials. Overall, while TXA is more potent and better studied, definitive clinical superiority over EACA remains unproven. Drug selection should therefore consider patient factors, institutional protocols, and resource availability pending further large-scale comparative trials.

Critical care transport and management in Earthquake catastrophes: Lessons from Japan

2025-12-23T21:48:08+07:00

Japan's experience with large-scale earthquakes has led to the development of a highly structured and adaptable disaster response system. This review highlights key lessons in critical care transport and disaster management from historical events such as the Hanshin-Awaji Earthquake (1995), and the East Japan Triple Disaster (2011). The "Point-Line-Plane" framework categorizes disasters by their geographical scale and helps guide tailored medical strategies. Critical care and emergency physicians must navigate the challenges posed by each disaster type, including triage, evacuation logistics, and continuity of care for vulnerable populations. The importance of Disaster Medical Assistance Teams (DMATs), staging care units, air transport, and chronic care networks in disaster response is highlighted. Previous experiences also emphasize proactive planning, multidisciplinary coordination, and robust healthcare infrastructure for better outcomes.