Mechanical power (MP) represents a useful parameter to describe and quantify the forces applied to the lungs during mechanical ventilation (MV). In this multi-center, prospective, observational study, we analyzed MP variations following MV adjustments after veno-venous extra-corporeal membrane oxygenation (VV ECMO) initiation. We also investigated whether the MV parameters (including MP) in the early phases of VV ECMO run may be related to the intensive care unit (ICU) mortality. Thirty-five patients with severe acute respiratory distress syndrome were prospectively enrolled and analyzed. After VV ECMO initiation, we observed a significant decrease in median MP (32.4 vs. 8.2 J/min, p < 0.001), plateau pressure (27 vs. 21 cmH₂O, p = 0.012), driving pressure (11 vs. 8 cmH₂O, p = 0.014), respiratory rate (RR, 22 vs. 14 breaths/min, p < 0.001), and tidal volume adjusted to patient ideal body weight (V_T/IBW, 5.5 vs. 4.0 mL/kg, p = 0.001) values. During the early phase of ECMO run, RR (17 vs. 13 breaths/min, p = 0.003) was significantly higher, while positive end-expiratory pressure (10 vs. 14 cmH₂O, p = 0.048) and V_T/IBW (3.0 vs. 4.0 mL/kg, p = 0.028) were lower in ICU non-survivors, when compared to the survivors. The observed decrease in MP after ECMO initiation did not influence ICU outcome. Waiting for large studies assessing the role of these parameters in VV ECMO patients, RR and MP monitoring should not be underrated during ECMO.

Veno-venous extracorporeal membrane oxygenation (V-V ECMO) represents a component of the treatment strategy for severe respiratory failure. Clinical evidence on the management of the lung during V-V ECMO are limited just as the consensus regarding timing of weaning. The monitoring of the carbon dioxide (CO₂) removal (V′CO₂TOT) is subdivided into two components: the membrane lung (ML) and the native lung (NL) are both taken into consideration to evaluate the improvement of the function of the lung and to predict the time to wean off ECMO. We enrolled patients with acute respiratory distress syndrome (ARDS). The V′CO₂NL ratio (V′CO₂NL/V′CO₂TOT) value was calculated based on the distribution of CO₂ between the NL and the ML. Of 18 patients, 15 were successfully weaned off of V-V ECMO. In this subgroup, we observed a significant increase in the V′CO₂NL ratio comparing the median values of the first and last quartiles (0.32 vs. 0.53, p = 0.0045), without observing any modifications in the ventilation parameters. An increase in the V′CO₂NL ratio, independently from any change in ventilation could, despite the limitations of the study, indicate an improvement in pulmonary function and may be used as a weaning index for ECMO.

Key Clinical Message: After risk assessment, veno‐venous extracorporeal membrane oxygenation (ECMO) has been achieved in a superobese adult patient as a bridge to recovery of respiratory failure, despite the weight‐related difficulties. Early v‐v ECMO implantation could be considered to support and to conduct weaning both from sedation and from invasive mechanical ventilation, with the goal to perform physiokinesitherapy during awake ECMO.

Background: Acute liver failure (ALF) is a life-threatening syndrome characterized by abrupt hepatic dysfunction accompanied by systemic inflammatory response and immune dysregulation, resulting in a high susceptibility to infectious complications. In the intensive care unit (ICU) setting, bacterial sepsis and invasive fungal infections represent critical determinants of multiorgan failure, liver transplant eligibility, and patient survival. Main body: This narrative review synthesizes current evidence on infectious risk, diagnostic challenges, and antimicrobial management in ALF. The immune response to massive hepatocellular necrosis is initially driven by damage-associated and pathogen-associated molecular patterns, resulting in a sepsis-like hyperinflammatory state. This phase is followed by profound immunoparesis, characterized by impaired innate and adaptive immune responses, which facilitates fbacterial translocation, increases susceptibility to nosocomial infections, and promotes colonization and infection with multidrug-resistant (MDR) pathogens. Infections occur in most ALF patients, yet differentiation between sterile systemic inflammatory response and sepsis remains challenging as fever, leukocytosis, and hemodynamic instability are nonspecific and microbiological cultures frequently yield negative results. Conventional biomarkers primarily reflect hepatocellular injury rather than bacterial infection. Antimicrobial therapy should be individualized based on clinical severity, local epidemiology, and MDR colonization, while accounting for profound pharmacokinetic alterations associated with hepatic failure. In liver transplant candidates and recipients, short-course perioperative prophylaxis and judicious interpretation of MDR screening are pivotal to prevent early postoperative infections without promoting antimicrobial resistance. Conclusions: Optimizing infection diagnosis, biomarker-guided decision-making, and individualized antimicrobial dosing in ALF, particularly in the peri-transplant ICU setting, is critical for improving patient outcomes and limiting the emergence of MDR pathogens.