A man in his early 70s presented with septic shock and severe ARDS, likely after aerosolising Francisella tularensis Initial empirical treatment for community-acquired pneumonia with ceftriaxone failed, resulting in clinical deterioration with stage 3 acute kidney injury requiring dialysis and necrotising pneumonia. After pneumonic tularaemia was identified, antimicrobial therapy was transitioned to renally dosed levofloxacin, along with aggressive ICU support including prone positioning and tube thoracostomy. The patient ultimately made a full recovery, returning to his functional baseline one month after discharge.This case underscores the importance of eliciting environmental exposures in patients with severe, culture-negative pneumonia unresponsive to beta-lactams, as this should prompt consideration of inhalational tularaemia. It also highlights how pathogen-induced cytokine storm can drive catastrophic multiorgan failure and supports fluoroquinolones as a safe and effective first-line alternative to aminoglycosides in the setting of renal failure.

Extracorporeal life support provides temporary cardiorespiratory support for patients with severe, potentially reversible cardiac and/or respiratory failure refractory to conventional measures. Its application has broadened across a wide spectrum of critical illness, yet the mechanistic basis of its physiological benefit remains incompletely defined.This review explores the mechanisms through which extracorporeal life support may confer benefit in respiratory and cardiac failure. These include restoration of gas exchange, optimization of circulatory dynamics, and mitigation of secondary organ injuries, creating conditions that facilitate tissue repair, enable adjunctive therapies, and in selected cases, provide a bridge to transplantation. In isolated respiratory failure, respiratory extracorporeal life support stabilizes gas exchange and modulates respiratory drive, enabling lung-protective ventilation and potentially attenuating ventilator- and patient self-inflicted lung injury. In cardiogenic shock, cardiac extracorporeal life support restores systemic perfusion and may reduce myocardial oxygen demand, while during cardiac arrest it may confer neuro-protective effects. In combined cardiorespiratory failure, advanced extracorporeal support modalities may augment both systemic and pulmonary circulation, supporting gas exchange and maintaining end-organ perfusion. Mechanistically, these interventions interrupt the cascade of hypoxemia- and/or hypercapnia- induced pulmonary vasoconstriction, right ventricular overload, and systemic hypoperfusion, facilitating multi-organ recovery. Optimizing patient selection, timing for extracorporeal life support initiation, and use of adjunctive therapies require a nuanced understanding of the interplay between these physiological pathways alongside careful considerations of key limitations including device-related complications, hematologic and inflammatory perturbations, and physiological trade-offs. This concise clinical review synthesizes the current literature on the mechanistic basis of extracorporeal life support in adults.

This study evaluated adherence to the 2021 Surviving Sepsis Campaign (SSC) guidelines for managing sepsis and septic shock in a tertiary intensive care unit (ICU), aiming to identify deviations from recommended practices and their clinical implications. A prospective observational study was conducted over six months in the ICU of an academic tertiary-care hospital. Patients aged 50-80 years with sepsis or septic shock were enrolled (n=138). Adherence to 17 SSC 2021 recommendations was assessed using structured case report forms and electronic medical records, and clinical parameters, therapeutic interventions, and outcomes were analysed to determine adherence rates and areas of nonadherence. Adherence was high for foundational resuscitative measures, including early administration of intravenous crystalloids (100%), maintenance of mean arterial pressure (MAP) ≥ 65 mm Hg (100%), and comprehensive medication reconciliation (100%). In contrast, adherence to the recommendation against using the Quick Sequential Organ Failure Assessment as a sole screening tool was 0%. Adherence was suboptimal for low-molecular-weight heparin as the preferred agent for venous thromboembolism prophylaxis (57.1%) and for lung-protective ventilation in acute respiratory distress syndrome (75%). ICU mortality was 16.7%, and the 30-day readmission rate was 23.9%. While adherence to core resuscitative components of the SSC guidelines was robust, important gaps persisted in diagnostic screening practices, thromboprophylaxis choice, and ventilatory strategies, highlighting actionable targets for quality improvement.

Extracorporeal life support (ECLS) is increasingly used to rescue patients with refractory respiratory failure, cardiogenic shock and/or cardiac arrest. Acute brain injury during ECLS is common and associated with a significant increase in mortality and long-term disability. Brain injury in ECLS patients can arise from either the underlying disease or pre-ECLS events, such as cardiac arrest, or from secondary mechanisms linked to ECLS-related complications, management strategies, and physiologic perturbations during support. In this review, we will focus on the modifiable factors and clinical management strategies to prevent or mitigate secondary brain injury during ECLS. Both veno-arterial membrane oxygenation (VA-ECMO) as well as veno-venous membrane oxygenation (VV-ECMO) will be discussed. First, we provide an overview of the interplay between patient and circuit related factors that determine brain perfusion and oxygen delivery in this critically ill patient population. Second, we highlight the importance of standardized multimodal neuromonitoring to detect evolving brain injury early and to guide individualized neurocritical care and ECLS management. Third, we identify modifiable ECLS factors and physiological targets which minimize secondary brain injury. We provide guidance on the titration of extracorporeal blood flow and blood pressure targets, the amount of sweep gas flow and oxygen fraction, temperature control and anticoagulation management. A comprehensive understanding of ECLS physiology and circuit-patient interactions, integrated with protocolized multimodal monitoring, enables individualized adjustment of modifiable ECLS settings to prevent or mitigate secondary brain injury.