Laudański, Krzysztof

Stellate ganglion blockade (SGB) is an uncommon but increasingly relevant therapy used to modulate the autonomic nervous system and reduce the risk of atrial fibrillation (AF). This narrative review focuses specifically on the potential therapeutic role of SGB in new-onset perioperative atrial fibrillation (POAF), a complication associated with adverse long-term outcomes that may diminish the overall benefits of surgery. SGB may reduce AF through several inflammation-mediated mechanisms, including attenuation of direct sympathetic activation and modulation of perioperative inflammatory responses. Because the clinical effects of SGB may persist beyond the expected duration of local anesthetic nerve blockade, we emphasize immunomodulation as a potential mechanism sustaining its beneficial effects and influencing longer-term outcomes. In this review, we examine the immunological effects of SGB in the context of postoperative AF, with particular emphasis on human studies most relevant to clinical practice. Available evidence suggests that, beyond nonspecific inflammation, several less commonly studied cellular components, including mast cells and T cells, may contribute to the initiation and persistence of POAF. These findings support the hypothesis that SGB may reduce POAF by limiting stellate ganglionitis driven by perioperative localized leukocyte activation. Future studies should define the extent, timing, and frequency of this inflammatory process and determine whether specific inflammatory or autonomic phenotypes can identify patients most likely to benefit from SGB.

Variability in novel inflammatory markers (HBP and SAA) post-surgery could indicate ongoing perioperative inflammation. This pilot cohort study collected blood from 99 patients undergoing elective cardiac surgery at baseline, 24 hours, 7 days, and 3 months post-surgery. Inflammatory markers (HBP, SAA, PCT, CRP, IL-6) were measured with a point-of-care device. Demographic and clinical data were extracted from health records. Serum SAA increased significantly in the acute postoperative phase (M e [IQR];SAA baseline =81.1[87] vs SAA 24hr= 232.65[88.02];U[72]=2343,p<0.0001), remained elevated at 7 days (Me 7d =252.6[88.56];U[57]=1484,p<0.0001) and were still more pronounced than baseline at t 3m (Me 3m =118.44[101.52];U[38]=448,p=0.0008). HBP showed a significant rise at seven days (HBP baseline =45[26;89] vs HBP 7d =121[69.75;224.5]; U[56]=805,p<0.0001) then returned to near baseline by t 3m (Me 3m =32.5[15.75;98.5]). Traditional inflammatory markers PCT, CRP, and IL-6 demonstrated a rapid increase at t 24h and plateaued at t 7d . None of the biomarkers showed variability at baseline or postoperatively with preoperative status or postoperative complications. Cluster analysis of the inflammatory markers at 24 hours (t 24h ) identified distinct subgroups. Cluster #1-patients with a modest increase in all markers; Cluster#2 characterized with a robust increase in IL-6; Cluster #3 showed increase in CRP and decline in HBP; Cluster #4 showed a modest increase in IL-6 and decline in HBP; Cluster #5 represented a decline in both CRP and SAA. Patients in these clusters differ with respect to age, pre-existing peripheral artery disease, and borderline differences in perioperative acetaminophen use. SAA and HBP remain elevated longer than IL-6, CRP, and PCT after surgery, suggesting that inflammation may persist beyond 3 months.

Critical-grade insults (CGIs), such as sepsis, pose extreme challenges to host homeostasis. Although unfavorable immune responses in these conditions are commonly described as dysregulated, such perturbations are often defined retrospectively based on clinical outcomes rather than on the underlying immune processes. Here, I propose that, particularly in its early phase, the immune system response to sepsis reflects a high-stakes host response aimed at rapid control of the insult, albeit one that carries substantial risk to the host. If the inciting challenge is effectively contained, the immune response may resolve and transition toward tissue repair and recovery. Conversely, failure to control the insult may result in host death. In this context, the early immune response can be conceptualized within a “win versus loss” framework, where win is described as the ability to control inciting insult, while loss is host demise. Consequently, the term “dysregulation” may not fully capture the probabilistic feature of the initial response. Rather than representing a simple failure of control, this response may reflect an aggressive but potentially hazardous strategy that, in some cases, proves unsuccessful. Timely medical interventions, including appropriate antibiotic therapy, source control, or immunological endotype-based strategies, can modify CGI immunological trajectory by limiting insult burden and reducing the duration and intensity of the host response, thereby improving the likelihood of survival. Nevertheless, sustained or excessive early immune activation may disrupt regulatory networks, resulting in inevitable demise in some individuals, while others will exhibit an emergence of maladaptive allostatic states that can impair full recovery.

Background Medical providers often face challenges in accurately predicting the survival of critically sick patients. Optimistic forecasts can lead to the overuse of resources, while overly cautious predictions might restrict treatments. This study examines the role of specific psychological factors, analyzed realistically and holistically, in predicting survival outcomes for intensive care unit patients. Methods This single-center cohort study evaluated health care providers (e.g., physicians, residents and fellows, and advanced practice practitioners) using two 7-d clinical vignettes. Providers assessed the need for mechanical ventilation (MV), renal replacement therapy (RRT), a percutaneous endoscopic gastrostomy (PEG) tube, or palliative care. Psychological factors were measured using scales that assessed ambiguity tolerance, rationality versus emotional defensiveness, anxiety related to uncertainty, decision-making style, and risk taking. These psychological traits were analyzed using a more realistic and holistic approach, employing cluster techniques. Providers also determined whether they had enough information to evaluate the patient’s condition and compared their survival estimates to APACHE II scores. Results In general, engagement in MV and RRT was common by day 2, although physicians were significantly less likely to recommend RRT. Providers generally suggested starting a palliative care consultation by day 6, with a noticeable shift on day 4. Three distinct composite psychological groups emerged: optimistic denial individuals (ODI), optimistic providers (OP), and resilient providers (RP). While these composite psychological groups did not significantly influence engagement in mechanical therapies, they did affect palliative care decisions: RP were more likely to request palliative care, whereas ODI were much less likely to do so. In contrast, individual psychological traits had nonsignificant correlations with the decision to use therapies. Providers initially overestimated survival probabilities during the first 3 d compared with APACHE II survival estimates. However, after day 4, this trend reversed, with providers becoming significantly more pessimistic versus the predictive score and increasingly requesting palliative care involvement. Conclusions Providers’ psychological profiles, rather than their clinical experience, significantly influenced decisions about organ-support therapies and palliative care. Survival estimates showed a biphasic pattern: initially, providers overestimated survival compared with APACHE II predictions, then became more pessimistic and more likely to consult palliative care after day 4. Highlights Intensive care unit survival predictions by providers followed a biphasic pattern: optimistic early on, then increasingly pessimistic after day 4. Psychological traits such as denial and ambiguity tolerance influenced palliative care decisions more than clinical experience did. Resilient providers were more likely to initiate timely palliative care, while denial-prone providers delayed it. Clinicians and critical care teams should be aware of how their psychological makeup can affect patient care decisions and outcomes.

Background: Surgical trauma disrupts hormone networks, but the duration required for these systems to recover remains unclear. We hypothesize that significant perioperative stress would trigger protracted abnormalities of the thyroid axis extending past 28 days. Methods: This retrospective exploratory study analyzed opportunistically obtained thyroid-related laboratory values (free T3 [FT3], free T4 [FT4], and thyroid-stimulating hormone [TSH]) and serum albumin from electronic medical records of patients undergoing CABG, AVR, or PCI between 2017 and 2022. Preprocedural baseline values were compared with post-procedural serum levels measured during the acute peri-procedural period (0–30 days), early recovery (31–90 days), intermediate recovery (91–180 days), late recovery (181–365 days), medium-term follow-up (1–2 years), and long-term follow-up (>2 years). Results: Free T3 demonstrated early suppression across all procedures, most pronounced in CABG during the acute peri-procedural period, with partial recovery at later timepoints. AVR showed moderate suppression at early and long-term follow-up, while PCI demonstrated minimal and inconsistent changes. Free T4 remained relatively stable across procedures, with limited significant post hoc differences after adjustment. TSH showed significant temporal variability in CABG and AVR but not in PCI. Serum albumin demonstrated marked early decline, most pronounced in CABG, with partial recovery over time, whereas AVR showed delayed long-term suppression. Data availability declined substantially at later timepoints across all biomarkers. Conclusions: In this retrospective exploratory analysis, CABG was associated with the most pronounced early perturbations in thyroid and albumin trajectories, while PCI and AVR demonstrated more heterogeneous temporal patterns. These findings are hypothesis-generating and should be interpreted cautiously given non-protocolized laboratory follow-up, substantial missingness, and potential selection bias.

A growing number of data-driven clinical decision support (CDS) tools are incorporated into tele-critical care, but the clinician perceptions of their utility are largely unknown. The objective of this web-based survey study was to understand the perceived utility of data-driven CDS in tele-critical care. The survey had 158 respondents (1.1% response rate), with 51.3% stating they currently use a data-driven CDS tool. Of those who responded about the impact of data-driven CDS, most (62.0%) reported a meaningful impact on workup, evidence-based care, or patient outcomes. Survey participants found CDS most useful if they or their colleagues had positive experiences with it, especially if it was responsible for improved patient outcomes. Thus, data-driven CDS is perceived useful for tele-critical care services.

BACKGROUND: The implementation of data science concepts, skills, and tools in critical care research and practice faces multiple, complex barriers. METHODS: We developed an implementation science-based framework and method for measuring the adoption, implementation, and sustainment of data science concepts, skills, and tools in critical care—the Society of Critical Care Medicine (SCCM) Discovery Data Science Campaign (DSC) Implementation Research Logic Model (IRLM). Our IRLM specifies constructs for: 1) key determinants (i.e., barriers and facilitators) influencing the implementation of data science concepts, skills, and tools in critical care; 2) implementation strategies deployed by the SCCM Discovery DSC to address these determinants; 3) theorized mechanisms of action by which these strategies affect outcomes; and 4) upstream and downstream implementation outcomes influenced by implementation strategies. RESULTS AND CONCLUSIONS: We believe that our model can facilitate more rigorous measurement of theoretically grounded, empirically assessable factors driving implementation of data science concepts, skills, and tools in critical care.

OBJECTIVE: Volatile anesthetics (VAs) are gaining renewed interest as a sedation strategy in the intensive care, offering an alternative to traditional IV agents. VAs provide several pharmacologic advantages, including rapid onset and offset, minimal systemic metabolism, and favorable recovery profiles. Advances in delivery systems enabled the safe and practical administration of volatile agents in the ICU. Thus, we aimed to describe the pharmacology and safety aspects of inhaled agents as well as the systems designed to deliver VAs in the ICU. DATA SOURCES: Relevant literature was identified through PubMed and MEDLINE databases. STUDY SELECTION: Original research, review articles, commentaries, and guidelines addressing safety, efficacy, and use of VAs in adult ICU patients were included. DATA EXTRACTION: Studies were reviewed by the authors, with key findings summarized and organized by pharmacologic properties, delivery systems, and safety domains. DATA SYNTHESIS: VAs are halogenated hydrocarbons whose mechanism of action is not fully understood. Although the CNS is the primary site of action, the end-tidal concentration of exhaled anesthetic is used to monitor clinical effects such as immobility to a noxious stimulus. Inhaled agents have unique pharmacokinetics, minimal metabolisms, and distinct recovery. The side effect profile is also unique, with malignant hyperthermia being the most feared, yet rare complication. Two systems for inhalational sedation delivery are available internationally, with one currently under evaluation in the United States. The systems are composed of a miniature vaporizer, delivery controller, and a monitor. The systems have distinct safety considerations, such as tidal volume limits. CONCLUSIONS: VAs can be used as sedative agents in the ICU. This article comprehensively reviews the pharmacology of VAs along with their safety profile and describes the structure and function of miniature vaporizers currently available on the world market.

OBJECTIVES: Current research does not address the existence and impact of structured tele-critical care (TCC) training on the delivery of care in the ICU. This pilot study aimed to evaluate the association between on boarding elements focused on training and clinicians perceptions of delivery of care. DESIGN: Cross-sectional survey study. SETTING AND PARTICIPANTS: Critical Care professionals at four U.S. hospitals, professional meetings and Society of Critical Care Medicine’s International Membership base. Participants were active clinicians who practice in the TCC setting. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 432 participants responded to the survey, 227 met the eligibility criteria (52.5%) and were included in the analysis. Respondents were a multi-professional group of TCC clinicians aged between 35–55 years of age (56.4%). Seventy-four percent of respondents reported having orientation before providing TCC, 46% reported having formal mentorship, and 66% reported formal training on their institutional platform. Provision of orientation before participating in a TCC program was associated with higher ratings of feeling prepared (odds ratio [OR], 3.52; p < 0.001) and feeling accepted as part of the ICU team (OR, 2.21; p = 0.008). Mentorship was associated with feeling more prepared (OR, 8.2; p < 0.001) and higher comfort in delivering care (OR, 2.78; p = 0.016). Platform training was associated with feeling more prepared (OR, 4.66; p < 0.001), comfortable in delivering care (OR, 3.6; p = 0.002), feeling accepted as part of the team (OR, 3.18; p < 0.001), and more likely to participate in quality improvement (OR, 2.51; p = 0.001). A site visit also made a positive impact in feeling prepared (OR, 2.86; p < 0.001), comfortable (OR, 4.95; p = 0.002), feeling like recommendations were accepted (OR, 3.73; p < 0.001), more likely to recommend TCC (OR, 3.18; p = 0.001), and participating in quality improvement (OR, 3.24; p < 0.001). CONCLUSIONS: In this pilot study, structured training utilizing orientation, mentorship, and platform training as surrogates, along with a site visit before beginning delivery of care in a TCC setting, were associated with more positive perceptions in the delivery of care domains assessed. We highlight potentially important factors that warrant further evaluation and assessment of the need for standardization across TCC programs.