Blood component transfusion remains a common intervention in critically ill patients and is primarily used to support oxygen delivery and correct coagulopathy. Over the past two decades, evidence from randomized trials and systematic reviews have supported the adoption of restrictive transfusion strategies in most critically ill populations. However, transfusion decisions should be individualized in patients with conditions involving ischemia-sensitive organs, including acute myocardial infarction and acute neurologic injury, where higher thresholds may be appropriate. Management of bleeding and coagulopathy in critical illness also involves platelet transfusion, coagulation factor replacement, and antifibrinolytic therapy. Increasingly, viscoelastic assays are used to guide targeted hemostatic therapy. Although transfusion can be lifesaving, it carries potential risks including transfusion reactions, circulatory overload, and transfusion-related lung injury. Optimal transfusion practice therefore requires balancing physiologic need with transfusion-related risks while applying evidence-based thresholds within the clinical context of critical illness.

Traditional Extracorporeal Blood Purification (EBP) rationales have focused on a concentration-dependent hypothesis of cytokine removal. However, emerging evidence suggests that a strictly plasma-centric interpretation is insufficient due to multicompartmental solute kinetics. This review proposes a comprehensive mechanistic framework for EBP, integrating mediator-directed and cell-directed immunomodulation. While mediator-directed therapies (e.g., AN69ST, PMMA membranes, and selective sorbents) aim to reduce the circulating burden of PAMPs and DAMPs, cell-directed interventions (e.g., PMX-HA, SCD) focus on "reprogramming" activated or exhausted leukocytes to restore immune homeostasis. The transition toward precision medicine in sepsis requires the integration of theragnostic biomarkers-such as mHLA-DR, NLR, and NETosis markers-to identify specific immune endotypes. Ultimately, EBP must evolve from device-agnostic applications to phenotype-driven approaches that optimize the timing and selection of extracorporeal support to improve clinical outcomes.

Acute kidney injury (AKI) is a common syndrome in critically ill patients, carrying significant implications for morbidity and mortality. The etiology and severity of AKI vary, requiring a management approach that focuses on prevention, treatment of the underlying cause, and supportive care, often involving renal replacement therapy. Numerous strategies have been proposed for preventing and treating AKI. This narrative review aims to provide a concise summary of the clinical management of AKI in critically ill patients tailored to clinicians working in the perioperative setting.

Anesthesia for liver transplantation poses myriad challenges due to surgical complexity and the multisystem pathophysiology associated with end-stage liver disease. Cirrhosis-related pathologies such as portopulmonary hypertension and hepatorenal syndrome may further complicate perioperative management, and intraoperative complications such as the development of intracardiac thrombus or post-reperfusion syndrome can cause catastrophic hemodynamic consequences that require advanced management, including mechanical circulatory support. This review summarizes recent advances in liver transplant anesthesia to inform best practices for managing this increasingly complex patient population.

Stress-induced cardiomyopathy (siCM), also known as Takotsubo syndrome, is an acute, transient, and typically reversible form of myocardial dysfunction. In the intensive care unit (ICU), siCM remains underrecognized because its clinical presentation, electrocardiographic abnormalities, and biomarker profile often overlap with acute coronary syndromes and other critical illness-associated cardiomyopathies. Unlike the emotional triggers commonly described in ambulatory populations, ICU-associated siCM is more frequently precipitated by severe physiologic stressors, including sepsis, neurologic injury, respiratory failure, major surgery, and exposure to vasoactive therapies. The pathophysiology of siCM is multifactorial and incompletely understood but appears largely driven by excessive sympathetic activation and catecholamine-mediated myocardial injury. Additional contributory mechanisms include coronary microvascular dysfunction, myocardial metabolic stress, neurocardiac axis dysregulation, and inflammatory signaling. Individual susceptibility factors, including postmenopausal estrogen deficiency and genetic variation in adrenergic pathways, may further increase vulnerability. Early recognition and ICU-specific diagnostic strategies are essential to improve management and outcomes in critically ill patients.

Pain management and sedation for critically ill patients remain areas of active interest and debate among intensivists. We review the foundational literature behind practices now considered the standard of care, including a systematic approach to target light sedation as well as the avoidance of benzodiazepine use. These approaches facilitate earlier liberation from mechanical ventilation, shorten intensive care unit length of stay, and reduce delirium. We also discuss the relative merits of dexmedetomidine versus propofol, analgesia-first sedation protocols, emerging medications and areas for future investigation.

Post-intensive care syndrome (PICS) is a common and multifaceted consequence of critical illness, affecting more than half of ICU survivors and encompassing persistent physical, cognitive and mental health impairments that may last for years and impair quality of life and functional recovery. Physical limitations, including ICU-acquired weakness and reduced exercise capacity, frequently coexist with mental health disorders and cognitive impairment. The burden extends to family members (PICS-F), who commonly experience psychological distress and reduced well-being. Risk factors include premorbid vulnerability as well as ICU-related exposures and complications. Preventive strategies focus on optimizing ICU care, particularly through the ABCDEF bundle (Assess, prevent and manage pain; Both spontaneous awakening and breathing trials; Choice of analgesia and sedation; Delirium assessment, prevention and management; Early mobility and exercise; and Family engagement and empowerment), while structured follow-up with early, targeted screening in high-risk patients is recommended to identify impairments and guide management across the recovery continuum.

Patients admitted to the intensive care unit (ICU) after major surgery frequently develop anorexia, feeding intolerance, and hyperglycaemia in response to the severe stress. Although observational studies have associated accumulation of a caloric deficit with poor outcome, randomised controlled trials (RCTs) have shown that early nutrition support induces dose-dependent harm in ICU patients, which has been attributed to aggravation of hyperglycaemia and associated metabolic damage, as well as suppressed cellular repair mechanisms. Hence, early full nutrition support, including early parenteral nutrition, should be avoided. The ideal blood glucose control target depends on the context. Tight blood glucose control (TGC) may be superior, but should only be performed when it can be achieved with a protocol that avoids hypoglycaemia. Safe TGC requires a protocol that includes regular, accurate blood glucose measurements and avoidance of insulin boluses. In the absence of such protocol, at least severe hyperglycaemia and hypoglycaemia should be avoided.

Point-of-Care Ultrasound (POCUS) has become a core competency for the anaesthesiologist managing patients in the postoperative intensive care unit. By providing immediate bedside imaging without consultative delay, it enhances diagnostic accuracy and directly informs haemodynamic and respiratory decision-making. This review addresses five clinical domains: lung and diaphragm assessment, cardiac evaluation and shock classification, fluid management, abdominal screening and deep vein thrombosis assessment, and procedural guidance. For each domain, sonographic findings, clinical interpretation, and management implications are described. A structured multi-organ approach with mandatory re-evaluation after every intervention is emphasised throughout. Governance requirements, including competency assessment, image archiving, and peer review are discussed alongside their medico-legal implications. Diagnostic accuracy is well established across all domains; randomised outcome data remain the principal evidence gap. Artificial intelligence may reduce operator dependency but requires prospective perioperative validation before routine implementation.

Acute brain injury is a leading cause of ICU admission and long-term disability. Clinical neurological examination is frequently limited by sedation and mechanical ventilation, making objective physiological monitoring essential. While intracranial pressure remains the cornerstone of neurocritical care, pressure alone provides an incomplete picture of the complex pathophysiology underlying secondary brain injury, and contemporary practice has progressively moved toward multimodal neuromonitoring strategies. This narrative review summarizes the most widely used neuromonitoring techniques beyond clinical examination and neuroimaging, describing their physiological rationale, available evidence, clinical indications, and practical limitations. Invasive ICP monitoring, non-invasive estimation methods, cerebral perfusion and autoregulatory assessment, oxygenation-based monitors, cerebral microdialysis, and neurophysiological techniques are systematically addressed. Randomized evidence supporting these modalities remains limited, and most recommendations derive from observational studies and expert consensus. The integration of complementary monitors within individualized, goal-directed frameworks represents the current standard in advanced neurocritical care practice.

Adrenal crisis is a life-threatening condition which is caused by an insufficient level of glucocorticoids in the body. Most patients have preexisting adrenal insufficiency, and physical or emotional stress triggers the adrenal crisis. This includes acute illness and surgery. It is important that patients receive a life-saving emergency injection of 100 mg hydrocortisone immediately and a continuous supplementation afterwards. This article focuses on the pathophysiology, trigger factors, prevention and emergency treatment of adrenal crisis in adult patients. By adjusting the regular dosage of glucocorticoids in stressful situations, adrenal crisis can be prevented. Patients at risk for adrenal crisis should keep an emergency injection kit and a standardised European emergency card and receive life-saving doses of glucocorticoids in emergency situations as quickly as possible.

With increases in patient acuity, the use of devices that provide Mechanical Circulatory Support (MCS) is increasing rapidly. By extension, anesthesiologists are increasingly called upon to manage patients supported by MCS. The type of MCS can be categorized into left ventricular support, right ventricular support, biventricular support, and whether or not respiratory support (oxygenation and ventilation) is provided. Examples of MCS types include intra-aortic balloon pump (IABP), venoarterial extracorporeal membrane oxygenation (VA ECMO), venovenous ECMO, and transvalvular microaxial flow pumps. Clinical scenarios include patients already supported by MCS devices that require a procedure (such as exploratory laparotomy), patients requiring planned periprocedural support (such as VA ECMO for ventricular tachycardia ablation), and patients that acutely decompensate and require emergent rescue (such as cardiac arrest requiring VA ECMO). This review presents the available literature on select MCS types, anesthetic considerations by MCS type, and future research directions.

Acute respiratory distress syndrome (ARDS) is a form of acute lung injury characterized by increased alveolar-capillary permeability and non-cardiogenic pulmonary edema. Mechanical ventilation remains the cornerstone of supportive care, but ventilatory support itself can worsen lung injury. Current guidelines recommend focusing on minimizing ventilator-induced lung injury through volume and pressure limitation (lung-protective ventilation). In selected patients, noninvasive strategies such as high-flow nasal cannula and noninvasive ventilation may prevent intubation. For patients requiring invasive ventilation, lung-protective ventilation (low tidal volume, limitation of plateau and driving pressures, positive end-expiratory pressure titration), prone position, and judicious use of neuromuscular blockade improves outcomes in moderate and severe ARDS. Advanced bedside monitoring tools, including esophageal pressure manometry, electrical impedance tomography, computed tomography, and lung ultrasound, have been proposed in the literature to monitor respiratory mechanics, regional ventilation, and recruitability, enabling clinicians to tailor ventilatory strategies to individual physiology.