In pediatric cardiogenic shock, endotracheal intubation may carry a high risk of cardiac arrest during anesthesia induction. This single-center retrospective case series (2020-2025) evaluated the feasibility, safety, and outcomes of ultrasound (US)-guided ilioinguinal-iliohypogastric (IhIG) nerve blocks (0.05-0.1 ml/kg of 0.25% ropivacaine) under light sedation to facilitate awake venoarterial extracorporeal membrane oxygenation and Impella (ECPella) surgical cannulation. Five adolescents (median age: 13 years, range: 7-17; median weight: 45 kg, range: 21-58) with nonpostcardiotomy cardiogenic shock underwent successful IhIG block placement in the pediatric intensive care unit by anesthesia-trained intensivists, followed by surgical cannulation in the catheterization laboratory. Intubation and mechanical ventilation were avoided during initial cannulation and throughout ECPella duration. Three patients required a modified chimney Y-graft for cannula placement, and two experienced local surgical bleeding. All five patients survived to hospital discharge, with three achieving direct biventricular recovery. Based on these preliminary data, US-guided IhIG nerve block seems a feasible and safe strategy for awake ECPella cannulation in selected pediatric patients, successfully avoiding high-risk invasive ventilation and general anesthesia.

In the absence of guidelines from professional societies, periprocedural fasting practices in enteral nutrition vary widely and often lead to preventable, clinically significant nutritional deficits. To address the heterogeneity of current clinical practice, the authors aimed to develop expert consensus on best practices for the periprocedural management of tube feeding using a modified Delphi consensus process. Draft recommendations were iteratively modified during a four-round Delphi process by a multidisciplinary international panel of experts. After iterative consolidation and modification, a total of 20 recommendations were produced by round 4, and all recommendations achieved stability. Final recommendations advocate for the protocolization of institutional perioperative fasting approaches and establish best practices for perioperative management of tube feeding in patients with and without a secure airway (cuffed endotracheal or cuffed tracheostomy tube) across a range of common clinical scenarios. The recommendations are intended to harmonize local practices internationally and safely minimize unnecessary periprocedural nutritional loss.

Sepsis remains one of the leading causes of death worldwide, and decades of immunomodulatory trials targeting inflammation have failed to improve outcomes, largely because of the biological heterogeneity of the host response. Triggering receptor expressed on myeloid cells-1 (TREM-1) has emerged as a particularly relevant pathway in this context: rather than initiating pathogen recognition, TREM-1 amplifies signals generated by pattern-recognition receptors, acting as a rheostat that fine-tunes the magnitude of the innate immune response to promote antimicrobial defense while limiting inflammation-induced tissue injury. Both insufficient and excessive activation of this pathway have been associated with adverse outcomes in experimental and clinical studies. Soluble TREM-1 (sTREM-1), released proportionally to pathway activation, has been extensively investigated as a biomarker of infection and disease severity. Its diagnostic performance is moderate and best interpreted alongside clinical and microbiological data, but its prognostic value is more consistent, particularly when assessed serially or combined with complementary host-response markers. More recently, sTREM-1 has been explored as a theranostic biomarker to guide pathway-directed treatment. Nangibotide, the most clinically advanced TREM-1 inhibitor, has demonstrated feasibility and short-term safety across phase 1 and phase 2 trials, but has not yet met its primary efficacy endpoint in an unselected population; exploratory analyses suggest that treatment benefit may be concentrated among patients with the highest baseline sTREM-1 concentrations, a hypothesis that remains to be prospectively validated. This review summarizes the biology of the TREM-1 pathway, the clinical evidence supporting sTREM-1 as a diagnostic, prognostic, and theranostic biomarker, and the current state of TREM-1-targeted therapeutics. It also discusses what the clinical development of nangibotide illustrates about the hope and the difficulty of precision immunomodulation in sepsis.

Cervical cannulation is the standard approach for venoarterial extracorporeal membrane oxygenation (VA-ECMO) in neonates and small children but is traditionally performed surgically. We report our initial experience with bedside percutaneous ultrasound- and echocardiography-guided cervical VA-ECMO cannulation performed by intensivists. Three pediatric patients underwent percutaneous right common carotid artery and internal jugular vein cannulation. Vascular access, guidewire advancement, tract dilation, and cannula positioning were guided by ultrasound and transthoracic echocardiography. Median age was 5 months (range, 20 days-6 years) and median weight 7 kg (range, 3-15 kg). Extracorporeal membrane oxygenation was initiated for extracorporeal cardiopulmonary resuscitation in two patients and refractory cardiogenic shock in one. Cannulation was successful in all patients without surgical conversion, with a median skin-puncture-to-flow time of 32 minutes (range, 28-35). Target flow (>100 ml/kg/min) was achieved in two patients. No major cannulation-related vascular or cardiac complications occurred. Two patients died on ECMO, while one survived without signs of stroke on follow-up magnetic resonance imaging. Vascular integrity was documented by postmortem examination or Doppler follow-up. Bedside percutaneous echo-guided cervical VA-ECMO cannulation by experienced intensivists appears technically feasible in pediatric patients. Further studies are needed to establish safety, reproducibility, effectiveness, and potential advantages over conventional surgical cannulation.

Trauma-induced coagulopathy (TIC) at admission to the emergency department is associated with severe bleeding, massive transfusion, increased morbidity, and mortality. There are significant regional variations in the accessibility and acceptance of point-of-care technology, such as viscoelastic hemostatic testing (VET), for coagulation monitoring and bleeding management in the Arabian Gulf council countries (GCC). Notable regional differences among these countries are mainly due to variation in the awareness of the benefits of VET-guided bleeding management using rotational thromboelastometry (ROTEM) or thromboelastography (TEG), compared with a transfusion ratio-based approach using shock packs, rather than for economic reasons. This review highlights the superiority of VET-guided bleeding management in severe trauma over conventional coagulation tests (CCTs) for early TIC detection and the importance of monitoring hemostatic disorders, whether hypocoagulability or hypercoagulability. VET consistently outperforms traditional coagulation tests in detecting early coagulation abnormalities and predicting massive transfusion and mortality in major trauma. Besides hyperfibrinolysis, fibrinogen deficiency often represents the first issue in TIC. Recent meta-analyses consistently demonstrated a reduction in mortality by implementing VET-guided bleeding management algorithms in severe trauma. Several studies demonstrated that VETs are valuable tools for massive transfusion and mortality prediction in bleeding patients with severe trauma. There is a notable variation in VET adoption and practice across trauma settings in the Arab Gulf. GCC-specific primary evidence is limited, with the Qatar cohort representing the largest directly identified regional study.

Background: Procalcitonin (PCT) may support decision-making in abdominal and emergency surgery when infection is difficult to distinguish from non-infectious inflammation. Its interpretation remains challenging because clinical settings, sampling schedules, and proposed thresholds vary. This WSES position paper examines the evidence across six clinical scenarios to provide a practical framework for PCT-informed decision-making. Methods: A structured literature review covering January 1980 to December 2025, with targeted updates through August 2026, informed six PICO-based clinical questions. Evidence appraisal drew on selected GRADE domains, including consistency, directness, and precision. Recommendations were developed through iterative expert review and consensus. Results: The panel formulated six conditional recommendations addressing intra-abdominal infection diagnosis, antibiotic discontinuation after source control, suspected source-control failure, infected pancreatic necrosis, infectious complications after trauma, and postoperative anastomotic leak. The panel's qualitative assessment rated evidence certainty as moderate for antibiotic discontinuation and the pancreatitis domain, and low for the remaining domains. Serial PCT trends may complement clinical assessment in selected patients. Evidence for reduced antibiotic exposure with predefined PCT algorithms is more established than evidence that PCT-informed imaging, reintervention, or discharge decisions improve patient outcomes. Conclusions: PCT-informed decision-making in abdominal surgery may contribute to a more individualized approach to emergency surgical care and precision emergency surgery. When interpreted as part of serial assessment and integrated with clinical judgement, organ-dysfunction trends, microbiology, imaging, and evaluation of source-control adequacy, PCT may support individualized antibiotic discontinuation, potentially earlier recognition of an unfavourable clinical course, and more timely diagnostic and source-control reassessment. Current evidence does not support universal thresholds or routine serial testing in all surgical patients. Biomarker kinetics should strengthen, but not replace, surgical reasoning or independently determine antimicrobial, imaging, or interventional decisions. Future research should validate setting-specific thresholds and sampling schedules, establish whether PCT provides actionable information before clinical deterioration, and evaluate the clinical effects and cost-effectiveness of PCT-informed pathways.

Penetrating cardiac injuries carry exceptionally high mortality, especially when the left ventricle is involved, and survival hinges on rapid diagnosis and immediate surgical intervention. We describe a case of penetrating cardiac trauma with acute tamponade, emphasizing the role of coordinated care from scene to operating theatre. A 30-year-old male presented with multiple precordial stab wounds, in hemorrhagic shock with severe hypoxemia; prehospital teams prioritized rapid stabilization and transport. On arrival, extended focused assessment with sonography for trauma (eFAST) identified left hemopneumothorax and circumferential pericardial effusion consistent with tamponade, and the massive transfusion protocol was activated. Emergency median sternotomy revealed a grade IV left ventricular laceration, which was repaired primarily without cardiopulmonary bypass, and the patient recovered well, with progressive hemodynamic stability and favorable metabolic parameters postoperatively. This case illustrates that survival from penetrating left ventricular injury requires rapid diagnosis via point-of-care ultrasound, immediate median sternotomy, and intensive postoperative management, and demonstrates that favorable outcomes are achievable through coordinated multidisciplinary care within an organized trauma system. Penetrating cardiac injuries remain time-critical emergencies, and early recognition via point-of-care ultrasound, prompt surgical access, and a well-rehearsed trauma protocol can achieve survival even when severe ventricular injuries are present.

Patients with acute right heart failure or pulmonary hypertension require cautious resuscitation because the right ventricle is highly preload-sensitive and has a narrow therapeutic window; both hypovolemia and volume overload may worsen hemodynamics. Echocardiographic guidance can help optimize fluid administration. The management of right heart failure also includes increasing contractility and reducing systemic afterload with inodilators such as dobutamine and milrinone. In cases of high pulmonary vascular resistance (PVR) contributing to right heart failure, the use of selective pulmonary dilators can decrease the right ventricular afterload, while largely avoiding the systemic hypotension associated with intravenous vasodilators. Hypoxemia, hypercapnia, and acidosis may increase PVR, while sedation, intubation, and positive-pressure ventilation (PPV) may reduce preload, precipitating hemodynamic collapse. When possible, noninvasive respiratory support may be cautiously used to optimize oxygenation and ventilation and avoid intubation. With either form of PPV, airway pressures should be minimized to reduce the risk of hemodynamic compromise. Additionally, preload should be carefully optimized; hypotension-inducing sedatives, such as propofol, should be minimized; vasopressors should be readily available. In ARDS complicated by acute cor pulmonale, a right ventricular-protective ventilation strategy should be considered alongside conventional lung-protective ventilation. This approach emphasizes limiting excessive plateau and driving pressures, avoiding severe hypercapnia and hypoxemia, and carefully titrating positive end-expiratory pressure (PEEP) to prevent excessive increases in PVR and right ventricular afterload. In patients with right-to-left intracardiac shunting, elevated right-sided pressures may worsen shunt flow and cause refractory hypoxemia that responds poorly to increasing FiO2 and ventilation pressures. Management should therefore focus on reducing PVR, optimizing right ventricular function, and limiting factors that increase right-sided pressures.

•Amniotic fluid embolism is a rare condition with high maternal mortality. It typically occurs during labor or delivery, and the pathogenesis has not yet been fully elucidated. •Survival of parturients with amniotic fluid embolism requires early recognition, rapid initiation of treatment, and access to skilled care based on the management of critically ill obstetric patients. •The classic clinical presentation of amniotic fluid embolism involves sudden hypoxia and hypotension or cardiopulmonary arrest, accompanied or immediately followed by non-cardiogenic pulmonary edema and hemorrhage secondary to disseminated intravascular coagulation. •In cases of amniotic fluid embolism occurring during labor, bleeding typically originates at invasive interventions sites (intravascular lines and urinary catheterization). Following vaginal or cesarean delivery, bleeding arises primarily from the uterus, birth canal lacerations, and incision sites (abdominal wall and episiotomies). •Key laboratory abnormalities observed in amniotic fluid embolism include decreased fibrinogen levels, thrombocytopenia, and elevated D-dimer levels. The latter has limited diagnostic value, as levels are typically elevated during pregnancy and the postpartum period. •Arterial blood gas analysis in amniotic fluid embolism indicates the presence of hypoxemia and metabolic acidosis. Although chest radiography is initially unremarkable, if pulmonary edema and respiratory distress syndrome are present, dense bilateral pulmonary infiltrates may be observed. •The identification of amniotic fluid debris in pulmonary artery catheters or histopathological samples of lung tissue should not be considered diagnostic of amniotic fluid embolism. •The primary goals in managing amniotic fluid embolism are cardiopulmonary resuscitation, hemorrhage control, reversal of coagulopathy, and when indicated, fetal delivery. •In cases of amniotic fluid embolism accompanied by coagulopathy, massive transfusion is a necessary measure for effective, definitive treatment. The infusion of uterotonics, non-surgical invasive interventions (intrauterine balloons and intrauterine suction systems), and surgical procedures (vascular ligation, uterine compression sutures, and hysterectomy) may be used as adjuncts to control hemorrhage but are not considered definitive treatments. •The main differential diagnoses for amniotic fluid embolism include complications of neuraxial anesthesia; hemorrhage due to uterine atony, retained products of conception, and/or birth canal trauma; placental abruption; pulmonary thromboembolism; air embolism; acute myocardial infarction; and anaphylactic, cardiogenic, or septic shock.

Hemorrhagic shock (HS) is a condition associated with organ failure. Animal models are widely used to study pathophysiology and potential therapies. Our aim was to clarify how anesthetic choice, shock duration, decompensation phase length, and time post-reperfusion influence plasma damage markers in HS. For this, male rats were anesthetized with either thiopental or ketamine/xylazine and subjected to HS. Blood pressure was reduced to 40 mmHg for 60 or 90 minutes, followed by reperfusion with shed blood. Blood samples were collected 4 or 24 hours after reperfusion. Liver and renal damage were observed in animals that underwent a 90-minute shock, but not a 60-minute shock. Animals anesthetized with ketamine/xylazine exhibited higher hepatic aminotransferases levels than those anesthetized with thiopental, suggesting more severe liver injury in the former group. AST levels were higher 4 hours after reperfusion. The duration of decompensation phase was positively correlated with liver injury but not with kidney dysfunction. Cardiovascular parameters and other organ damage markers were similar among the groups. Therefore, HS protocols in rats require a minimum of 90 minutes of the ischemic phase to induce consistent organ dysfunction detectable through plasma markers. The duration of the decompensation phase directly influences the outcome.