Computed tomography (CT) is widely used to evaluate emergency department (ED) patients with headache, increasing costs, radiation exposure, and workload. Non-invasive intracranial pressure waveform (ICPW) monitoring has been proposed as an adjunctive triage tool. We assessed its diagnostic performance for identifying abnormal head CT findings in ED patients with red-flag headaches and explored potential resource implications. This retrospective study included 84 patients with red-flag headaches at Hospital Leforte Morumbi, Brazil (June-September 2023). All underwent non-invasive ICPW monitoring (brain4care System) and head CT during the same ED encounter. ICPW was abnormal if P2/P1 ≥ 1.2 or time-to-peak (TTP) ≥ 0.3. Sensitivity, specificity, positive and negative predictive values (PPV, NPV) were calculated against abnormal CT. CT expenditure and ED length of stay were assessed as exploratory outcomes. ICPW showed 90.0% sensitivity, 66.2% specificity, 98.0% NPV, and 26.5% PPV for abnormal CT. Median P2/P1 ratio yielded an ROC AUC of 0.778 (95% CI 0.640-0.900). Forty-nine patients (58.3%) had both normal ICPW and normal CT; their median ED stay was 3.5 h shorter than that of the overall cohort, though causality cannot be inferred. One patient had normal ICPW despite abnormal CT. Hypothetically, the normal examinations represented a projected gross CT expenditure of US$34,300. The high NPV supports further investigation of ICPW as an adjunctive risk-stratification tool, but the retrospective single-center design, small sample, and few abnormal CTs preclude definitive conclusions. ICPW should not replace clinical assessment or neuroimaging; resource implications remain exploratory hypotheses requiring prospective, multicenter validation.

Peripheral intravenous (IV) catheter infiltration is a common complication which can cause harmful extravasation of fluid and medications. Significant injury can occur before standard infusion pumps detect a threshold pressure. Peripheral IV waveform analysis (PIVA) uses fast Fourier transform (FFT) to measure the amplitude of the venous waveform. This study aims to evaluate if PIVA can differentiate between IV catheter positions, primarily intravenous versus subcutaneous, in a rat model. Surgical cutdown was performed on the right proximal saphenous vein. Pressure and waveforms were recorded from a 22G IV catheter open-to-air, in the vein, and in the adjacent subcutaneous (SC) tissue. Measurements were performed at baseline and after injection of 1 mL Plasmalyte and are reported as median (interquartile range). The peak amplitude corresponding to the heart rate frequency labeled as f1. Pre-flush intravascular f1, 0.0824 mmHg (IQR 0.0256, 0.1480), differed significantly from both SC, 0.0001 mmHg (0.0000, 0.0004), and open-to-air, 0.0001 mmHg (0.0000, 0.0008), conditions, ANOVA p = 0.03, pairwise p = 0.049 and 0.049, respectively. These significant differences remained after flush. Post-flush pressures between IV, 7.9 mmHg (6.6, 8.9) and SC, 20.5 mmHg (11.3, 28.8) were significantly different, p = 0.0001. There was no significant difference in pre-flush and post-flush pressure within IV, SC, and open-air groups, p = 0.687, p = 0.110 and p = 0.219, respectively. PIVA was superior to absolute pressure measurement for detecting intravascular versus extravascular placement of an IV catheter. This study demonstrates utility of PIVA as a novel method for confirming proper IV placement.

Intensive care unit (ICU) delirium affects up to 50% of mechanically ventilated patients. This condition is associated with increased morbidity and mortality. Although bispectral index (BIS) monitoring is widely used for sedation assessment, its predictive value for delirium remains limited. Burst suppression (BS) is an electroencephalographic pattern reflecting profound cerebral dysfunction. BS has been proposed as a predictor of delirium. However, the quantitative role of burst suppression duration (BSD) in delirium risk stratification has not been established. This prospective observational study enrolled 300 mechanically ventilated adult ICU patients between April 2021 and October 2024 at Harrison International Peace Hospital. Continuous video-electroencephalogram (vEEG) monitoring was performed. BSD was quantified from the vEEG recordings. Delirium was assessed using the Confusion Assessment Method for the ICU (CAM-ICU). Multivariate logistic regression was used to identify independent risk factors. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the diagnostic performance of BSD. Among 300 patients, 130 (43.3%) developed delirium. The delirium group had significantly longer BSD than the control group (median 81.1 s, IQR 41.5-148.5 vs. 17.2 s, IQR 5.8-32.9; P < 0.001). Multivariate analysis identified BSD (adjusted OR = 1.018, 95% CI 1.012-1.023; P < 0.001), BIS (adjusted OR = 0.964, 95% CI 0.946-0.982; P < 0.001), age (adjusted OR = 1.024, 95% CI 1.002-1.047; P = 0.031), and hypertension (adjusted OR = 1.748, 95% CI 1.002-3.051; P = 0.049) as independent risk factors. ROC analysis demonstrated that BSD achieved an area under the curve (AUC) of 0.871 (95% CI 0.829-0.913). The optimal cutoff of 41.5 s yielded a sensitivity of 80.8% and a specificity of 78.2%. The combination of BSD and BIS improved the AUC to 0.914 (95% CI 0.882-0.946). BSD is an independent risk factor for delirium in mechanically ventilated ICU patients. It demonstrates high diagnostic accuracy as a quantitative biomarker. The combination of BSD and BIS provides superior predictive performance. This combined approach offers a practical quantitative tool for early delirium risk stratification.

Accurate, continuous blood pressure (BP) monitoring is important for preventing, diagnosing, and managing cardiovascular disease. Estimating the full arterial BP waveform can provide more clinical information than cuff-based measurements that report only systolic and diastolic BP. This review summarizes recent progress in predicting arterial BP waveforms from photoplethysmography (PPG) and identifies the main methodological gaps that limit clinical translation. We reviewed research published since 2021 on PPG-based BP waveform estimation. We organized the literature around core pipeline elements, including open-source datasets, preprocessing and quality control, model architectures, and validation practices. We also surveyed commercially available technologies that measure BP waveform. Data cleaning approaches can be grouped into three main categories: (1) template-based pulsation comparison, (2) feature extraction paired with classical machine learning, and (3) neural network-based quality assessment. For waveform prediction, recent work is dominated by deep learning, particularly U-Net-based architectures, autoencoder families, and attention-based models. Progress in PPG-based BP waveform prediction is rapid, but comparability and reproducibility remain major barriers. Benchmark datasets with consistent acquisition protocols, transparent preprocessing, and standardized validation criteria are needed to support fair comparison.

Quantitative neuromuscular (qNM) monitoring is recommended whenever neuromuscular blocking agents (NMBAs) are administered, but adherence in routine clinical practice remains inconsistent. This audit evaluated adherence to recommended qNM monitoring standards in adult patients undergoing general anesthesia at a Portuguese tertiary hospital. This prospective clinical audit evaluated adherence to recommended qNM monitoring standards in adult patients undergoing general anesthesia at a major Portuguese tertiary hospital. Over five predefined weekdays between March and May 2025, all adult patients receiving general anesthesia across six operating or procedural areas were assessed. Of 329 patients included, 308 (93.6%) received NMBAs. Quantitative neuromuscular monitoring was omitted in 13.0% despite universal device availability. Utilization was lower in ambulatory and obstetrical settings and in procedures lasting less than one hour. Increasing anesthesia duration was associated with greater monitoring use in univariable analysis, but this association was not independent of clinical location. Equipment-related limitations accounted for a small proportion of omissions. This audit demonstrates high but incomplete adherence to qNM monitoring standards. Non-adherence is clustered primarily in procedures lasting less than one hour and in ambulatory and obstetrical settings. Although equipment was universally available, factors beyond equipment availability appear to contribute to incomplete implementation. Additional research is required to better understand the reasons underlying monitoring omission. In the meantime, targeted educational strategies and reinforcement of evidence-based neuromuscular monitoring practices may further enhance perioperative patient safety.

Preoperative anxiety in pediatric patients remains a significant clinical challenge, yet existing interventions are limited by resource requirements and inconsistent effectiveness. The aim of this pilot study was to evaluate the feasibility and preliminary effects of a tablet-based augmented reality (AR) system integrated into routine perioperative patient transfer on preoperative anxiety in pediatric patients. In this single-center, quasi-experimental pilot study, 27 pediatric patients aged 3-10 years were assigned to an AR (n = 13) or control (n = 14) group based on surgery month. The AR system, implemented on a standard tablet device, overlaid virtual characters onto real-world surroundings to guide patients from the surgical center entrance to the operating room. The primary outcome was preoperative anxiety assessed using the modified Yale Preoperative Anxiety Scale (mYPAS) at operating room entry. Secondary outcomes included guardian-rated comfort visual analog scale scores and postoperative agitation. The AR group was younger than the control group. Median mYPAS scores at operating room entry were lower in the AR group than in the control group (28.3 [23.3-36.7] vs. 40.0 [36.7-52.9]; median difference - 11.7; 95% CI, - 18.4 to - 1.60; p = 0.01). No significant differences were observed in secondary outcomes. This pilot study demonstrates the feasibility of integrating a tablet-based AR system into perioperative workflows. Preliminary findings also indicate that this approach may help reduce preoperative anxiety in this population. Given the pilot nature of the study, non-randomized allocation, and baseline imbalances between groups, validation in larger, well-controlled, randomized trials is required.

Goal-directed fluid therapy (GDFT) relies primarily on macrocirculatory hemodynamic variables for optimizing fluid therapy. Patients undergoing gastric cancer surgery often present with anemia, which may impair microvascular endothelial function and tissue oxygenation. How preoperative anemia influences intraoperative sublingual microcirculation and macro- and micro-circulatory coherence under GDFT is not known. Patients undergoing open radical gastrectomy were divided into anemic and non‑anemic groups according to their hemoglobin (Hb) levels. All patients received GDFT guided by pulse pressure variation. Sublingual microcirculatory (microvascular flow index [MFI], proportion of perfused vessels [PPV], total and perfused vessel density) and macrocirculatory (cardiac index [CI] and mean arterial pressure [MAP]) variables were measured before (T0) and immediately after induction of general anesthesia (T1), after tumor resection (T2) and at the end of surgery (T3). Mixed linear models were used to compare intergroup differences in sublingual microcirculation over time, and to analyze the correlations between macro- and micro-circulatory variables. Correlations between preoperative Hb and changes in MFI from each intraoperative time point to T0 were additionally assessed. A total of 49 patients were analyzed in present study. MFI showed a significant group‑by‑time interaction between the two groups (P = 0.030). In anemic patients (n = 22), MFI was significantly lower than that in non‑anemic patients (n = 27) at T1 (P = 0.013), and between-group differences were no longer evident at T3 (P = 0.461) under GDFT, although MFI remained below baseline in both groups. PPV was lower in anemic patients at T2 (P = 0.010). Correlation analyses demonstrated that lower preoperative Hb levels were associated with greater reductions in ΔMFI from T1 to T0 (Pearson's r = 0.343, P = 0.016) and T2 to T0 (Spearman's ρ = 0.369, P = 0.009). No significant associations were found between macro- and micro-circulatory variables in either group. Under GDFT, anemic patients exhibited greater perioperative alterations in sublingual microcirculation, particularly after anesthesia induction and tumor resection. Lower preoperative Hb concentrations were associated with greater reductions in MFI. Further, the lack of detectable associations between macrocirculatory and sublingual microcirculatory variables suggests that conventional hemodynamic targets may not fully reflect sublingual microvascular perfusion in this vulnerable population.Trial registration number: NCT07583927.

To examine the association between intraoperative premature ventricular contraction (PVC) burden and 30-day major adverse cardiovascular events (MACE) in liver transplantation (LT) recipients, and to determine whether complex ventricular ectopy carries prognostic significance distinct from isolated PVCs. In this retrospective cohort study, continuous intraoperative ECG recordings from 2,290 consecutive LT recipients were analyzed using a validated AI-based detection pipeline. PVCs were classified as isolated or complex (couplet, NSVT, bigeminy, trigeminy), with total complex PVC burden as the primary exposure. Associations with 30-day MACE were estimated by multivariable logistic regression across burden tertiles. Sensitivity analyses used a hard MACE endpoint excluding arrhythmic components and with additional adjustment for isolated PVC burden. MACE occurred in 515 patients (22.5%). PVCs were detected in 98.2% of patients; isolated PVC prevalence did not differ between those with and without MACE (98.4% vs. 98.0%, P = 0.666), whereas complex PVC prevalence was significantly higher in the MACE group (93.2% vs. 85.8%, P < 0.001). Total complex PVC burden showed a graded association with MACE across tertiles (T1 aOR 1.71, 95% CI 1.11-2.65; T2 aOR 2.26, 95% CI 1.47-3.47; T3 aOR 2.79, 95% CI 1.83-4.27), whereas isolated PVC burden was not associated with MACE in any tertile. The association persisted in both sensitivity analyses. Complex intraoperative ventricular ectopy, but not isolated PVCs, was independently associated with 30-day MACE in LT recipients. AI-enabled PVC quantification may identify an intraoperative signal associated with postoperative cardiovascular risk, although prospective and external validation is required before clinical application.

In critically ill patients, intra-abdominal hypertension (IAH) is associated with organ dysfunction and increased mortality. Acute kidney injury may occur early, since the kidney is particularly vulnerable to elevated intra-abdominal pressure (IAP). Accurate and timely measurement of IAP is essential for early detection of IAH and the initiation of appropriate therapeutic interventions. Therefore, the aim of this study was to assess the accuracy of an IAP monitoring system compared to a reference standard, the CO2 insufflator, during laparoscopy. The second aim was to assess the changes in renal biomarker levels during and after increases in IAP through pneumoperitoneum. A prospective cohort study in patients undergoing laparoscopy at the University Medical Center Groningen. IAP measurements were performed with a urinary catheter using an IAP monitoring system (Accuryn® Monitoring System, Accuryn Medical) and compared to the pressure set at the CO2-insufflator system. Bland-Altman analysis was performed with accounting for repeated measures. Urine samples were collected at several time-points and Kidney Injury Molecule 1 (KIM-1), Tissue Inhibitor of Metalloproteinase 2 (TIMP-2), urinary Neutrophil Gelatinase-Associated Lipocalin (NGAL), Liver-type Fatty Acid-Binding Protein (L-FABP), and albumin-creatinine ratio were measured. Between March 2025 and January 2026, 99 measurements were performed in 29 patients. One patient (3%) underwent hemicolectomy, and 28 patients underwent endometriosis surgery (97%). Analysis showed a bias of -1.4 mmHg (95% CI (-1.96 - (-0.82)) and limits of agreement of - 5.96 mmHg and 3.2 mmHg (95% CI -6.8-3.99) between the IAP monitoring system and the CO2-insufflators. The precision was 2.3 mmHg. The levels of renal biomarkers KIM-1, TIMP-2 and albumin/Cr ratio increased during laparoscopy compared to baseline, suggesting that relatively small IAP increases during laparoscopy have a subclinical effect on the kidney. The IAP monitoring system underestimated the IAP set by the CO2-insufflator by approximately 1 mmHg. The wide limits of agreement warrant cautious interpretation. Overall, the IAP monitoring system showed reasonable accuracy and precision. The increase of several renal biomarkers during laparoscopy compared to baseline may reflect a direct effect of elevated IAP on the kidney.

The evolution of Capillary refill time (CRT) use in clinical medicine is interesting, transforming a simple bedside observation into a reliable tool for assessing tissue perfusion in critically ill patients. When Henry Beecher and colleagues first systematized CRT measurement in 1947, they recognized its potential as a rapid method to evaluate circulatory status in trauma casualties, establishing a foundational framework that would influence intensive care practice for decades to come. However, clinicians soon discovered that relying on visual inspection alone introduced troubling variability between observers and even within the same observer's assessments, with expertise and training significantly influencing measurement accuracy. This recognition of CRT's limitations sparked a concerted effort to transform the measurement from a purely subjective exercise into a standardized, objective clinical tool. Researchers systematically refined protocols by establishing consistent pressure application techniques, standardized measurement sites, and defined normal thresholds (approximately 3 s for healthy adults). These methodological advances set the stage for rigorous clinical validation. Subsequent research revealed that CRT correlated powerfully with microvascular blood flow and independently predicted mortality and organ dysfunction in septic patients. Meta-analyses encompassing over 60,000 patients confirmed that abnormal CRT carried substantially elevated mortality risk, particularly when measured using standardized techniques. More recently, the ANDROMEDA-SHOCK trials demonstrated that CRT could serve not merely as a prognostic marker but as an actionable resuscitation target. CRT is nowadays considered an adjunct bedside marker to guide fluid and vasopressor resuscitation in adults with sepsis and septic shock, supporting individualized hemodynamic strategies while reducing over-resuscitation risks.

Corticosteroid trials in septic shock show conflicting results, with patient heterogeneity and treatment timing as likely contributors. We evaluated whether associations between corticosteroid timing and clinical outcomes differed by hemodynamic trajectory phenotype defined by dynamic time warping clustering of Blood Pressure-Vasopressor Index (BPRI) trajectories across three ICU cohorts. We conducted a retrospective cohort study using MIMIC-IV as the derivation cohort and eICU-CRD and PINES as validation cohorts. Adult patients with septic shock receiving vasopressors were included. Hemodynamic phenotypes were identified from 168-h BPRI trajectories. Corticosteroid timing was classified as early (≤ 6 h) or late (> 6 h) after sepsis onset. In MIMIC-IV, inverse probability of treatment weighting with cause-specific Cox regression was used to estimate associations between timing and 28-day mortality, hospital length of stay, and ventilation duration within each phenotype. Validation cohorts were analyzed using multivariable Cox regression, and cohort-specific estimates were summarized using random-effects meta-analysis with I2. Two phenotypes were identified in MIMIC-IV: Deteriorated (N=2,082, 38%), with declining hemodynamics and higher mortality, and Improved (N=3,361, 62%), with stable or rising trajectories. Similar trajectory patterns were observed in eICU-CRD and PINES. In the Deteriorated phenotype, late corticosteroids were associated with lower 28-day mortality in MIMIC-IV (HR 0.88 [0.78-0.98]) and shorter ventilation duration (HR 0.65 [0.58-0.73]) compared with early administration. The mortality association was not consistently replicated in validation cohorts, whereas the ventilation association was observed in PINES Deteriorated patients. In the Improved phenotype, late steroids showed no consistent mortality or hospital length-of-stay association. Exploratory hemodynamic response analysis showed a more favorable BPRI slope for late versus early steroids in the Deteriorated phenotype. Hemodynamic trajectory phenotypes identified clinically meaningful variation in the relationship between corticosteroid timing and outcomes in septic shock. In the Deteriorated phenotype, delayed corticosteroid initiation was associated with lower 28-day mortality and shorter recovery, whereas the Improved phenotype showed no mortality advantage from delayed treatment. These findings support incorporating dynamic hemodynamic trajectories into future studies of corticosteroid timing in septic shock.