Venoarterial extracorporeal membrane oxygenation (V-A ECMO) is a technique used to provide short-term circulatory and respiratory support in patients with refractory cardiogenic shock and cardiac arrest who do not respond to conventional therapies. Due to its increased use in recent years, a thorough understanding of its pathophysiological effects, indications, monitoring, and clinical management is required. The present review provides a practical update on the management of adult patients receiving V-A ECMO support, covering hemodynamic effects on the native circulation, cannulation strategies, multimodal monitoring, and therapeutic goals in the different support phases. In addition, the main associated complications, escalation strategies, weaning criteria, and organizational aspects essential to ensuring safe and effective care are reviewed. Finally, this review discusses the ethical considerations inherent in the use of this complex therapy. This integrative and clinically oriented approach aims to support decision-making in Intensive Care Units managing highly complex patients.

Acute brain injury (ABI), including traumatic brain injury, ischemic and hemorrhagic stroke, is associated with high morbidity and mortality, which is driven not only by the primary brain injury, but also by the development of secondary cerebral insults. Among these, raised intracranial pressure (ICP) plays a central pathophysiological role, acting both as a consequence and a driver of ongoing brain injury through mechanical deformation and cerebral ischemia. Although invasive intracranial pressure (ICP) monitoring has a longstanding and ongoing role in neurocritical care management, the interpretation and clinical use of ICP remain controversial. Traditional management strategies rely on fixed ICP thresholds (e.g., > 22 mmHg) to trigger a standardized stepwise escalation of therapy; however, growing clinical evidence indicates that tolerance to ICP elevation varies widely across patients, disease entities, and physiological contexts. This review summarizes the physiological determinants of ICP, including intracranial compliance, cerebrospinal fluid dynamics, cerebral blood volume, and systemic factors, and describes the mechanisms underlying intracranial hypertension. We discuss limitations of using fixed ICP thresholds and highlight emerging concepts, such as ICP burden, waveform morphology, cerebral autoregulation, and functional brain monitoring, as tools to individualize ICP interpretation. The role of invasive and noninvasive ICP monitoring (nICP) modalities is reviewed, emphasizing the complementary value of nICP in guiding decision-making when invasive monitoring is unavailable or contraindicated. Particular attention is given to the integration of ICP within multimodal neuromonitoring frameworks assessing cerebral perfusion, oxygenation, and metabolism. Finally, we explore future perspectives, including the potential of artificial intelligence-based approaches to analyse complex neuromonitoring data, predict secondary insults, and move toward actionable, patientspecific therapeutic strategies. Collectively, these advances support a shift from a uniform, threshold-driven approach toward individualized, physiology-informed management of intracranial hypertension.

Making shared decisions in pediatric critical care, either with families and/or other professionals, is not an easy task and may lead to ethical conflicts, especially in children with chronic complex conditions and in end-of-life care. As professionals, we must be aware of these challenges and use the appropriate training and communication skills to develop a care plan that takes into account the best interests of minors. During the decision-making process, we must balance technical and scientific aspects, indications, alternatives, and expected outcomes, considering the goals of treatment as well as the proportionality of the therapies. We must also take into account prognostic uncertainty and the integral physical, psychoemotional, social, and spiritual nuances of the child and family. Whenever possible, anticipated care plans should be consensus-based. These plans should detail the information and communication process, the agreements reached, and indicate the path to be followed by the professionals involved.