Background/Objectives: Current guidelines recommend the use of clinical signs to diagnose shock and cellular hypoperfusion in critically ill patients. However, these recommendations are based on limited scientific evidence. The objective was to determine the predictive value of clinical signs to identify shock. Methods: Retrospective cohort study including adult (≥18 years) patients admitted to the critical care resuscitation unit of a tertiary hospital. The primary goal was to determine the predictive value of tachycardia, prolonged capillary refill time (CRT), skin mottling, weak radial pulse, inadequate peripheral perfusion, shock index > 0.8, altered mental state, and diaphoresis to identify shock. Two-by-two contingency tables were used for statistical analysis. Results: Three-hundred-seventeen patients (no shock, n = 231; shock, n = 86) were included. As a single clinical sign, skin mottling [sensitivity, 0.38; specificity, 0.92; negative likelihood ratio (LR−), 0.68; positive likelihood ratio (LR+), 4.62], prolonged CRT (sensitivity, 0.44; specificity, 0.89; LR−, 0.62; LR+, 4.17), shock index >0.8 [sensitivity, 0.77; specificity, 0.64; LR−, 0.36; LR+, 2.15], a weak radial pulse [sensitivity, 0.62; specificity, 0.79; LR−, 0.49; LR+, 2.88], and inadequate peripheral perfusion [sensitivity, 0.68; specificity, 0.73; LR−, 0.44; LR+, 2.52] predicted shock. Prolonged CRT, skin mottling, inadequate peripheral perfusion, a weak radial pulse, and a shock index >0.8 predicted shock states with low cardiac output. A shock index >0.8, tachycardia, and a weak radial pulse were predictive of distributive/vasodilatory shock. The accuracy to identify shock were higher if ≥2 clinical signs were present compared to only one. Conclusions: Skin mottling, prolonged CRT, shock index >0.8, weak radial pulse, and inadequate peripheral perfusion can identify patients with shock, particularly shock states with low cardiac output, with high specificity and LR+.

Data on factor XIII (FXIII) activity in patients on extracorporeal membrane oxygenation (ECMO) are scarce. In this prospective, observational, single-centre study, we determined the rate of acquired FXIII deficiency in 44 adults during ECMO. We evaluated the relationship between minimum FXIII activity, haemoglobin levels, transfusion requirements, as well as the occurrence of major bleeding events. Descriptive statistical methods, bivariate correlation and receiver operating characteristic curve analyses were applied. Acquired FXIII deficiency (FXIII activity < 70%) was found in 41/44 patients [93.2% (95% CI 85.7–100%)] during ECMO. The minimum FXIII activity was correlated with minimum haemoglobin levels (Spearman- rho , 0.331, 95% CI 0.02–0.57, p = 0.03), packed red blood cell transfusion requirements (Spearman- rho , − 0.32, 95% CI − 0.58 to 0.00, p = 0.03), but not the occurrence of major bleeding events ( p = 0.32, Hodges-Lehmann difference − 4.0%, 95% CI − 15.0 to 5.0%) during ECMO. The area under the receiver operating characteristic curve for minimum FXIII activity to predict the occurrence of major bleeding events during ECMO was 0.602 (95% CI 0.375–0.828). The lowest FXIII activity to predict a major bleeding event was 51.0% and 55.5% (Youden index for both, 0.27), respectively. In conclusion, acquired FXIII deficiency is highly frequent in adult ECMO patients. Lower FXIII activity showed modest correlations with nadir haemoglobin and pRBC exposure, but did not discriminate patients with major bleeding. Larger studies are needed to determine whether routine FXIII monitoring and targeted replacement improve outcomes during ECMO.

BACKGROUND: Current guidelines differ in their recommendations regarding the use of physiologic transfusion triggers to guide transfusion practice. Data on the interaction between haemoglobin (Hb) and physiologic transfusion triggers, or their response to packed red blood cell (pRBC) transfusions are limited. OBJECTIVES: This study aimed to evaluate the interactions between Hb, mixed/central venous oxygen saturation (SvO₂) and lactate levels as well as their changes (ΔSvO₂, Δlactate) in response to pRBC transfusion in cardiac surgery patients. DESIGN: Retrospective exploratory data analysis. SETTING: A 22-bed intensive care unit (ICU) at a single tertiary academic centre and university hospital in Austria. PATIENTS: Adult (age ≥ 18 years) patients who underwent cardiac surgery. MAIN OUTCOME MEASURES: Pearson correlation coefficients (r) and coefficients of determination (r ²) between Hb, mixed/central venous oxygen saturation (SvO₂), and lactate levels. Pearson correlation coefficients (r) and coefficients of determination (r ²) between ΔSvO₂, Δlactate and pretransfusion Hb. RESULTS: A total of 5025 cardiac surgery patients, in whom 20 542 blood gas analyses were performed, were included in the final analysis. Correlations between Hb levels and SvO₂ (r ² = 0.026, P < 0.001) and between Hb and lactate levels (r ² = 0.001, P < 0.001) were statistically significant but weak overall. No correlations were found between ΔSvO₂ (r ² = 0.002, P = 0.13) or Δlactate (r ² = 0.003, P = 0.087) and pretransfusion Hb levels. CONCLUSIONS: Hb, SvO₂ and lactate levels were only weakly correlated with each other, and changes in SvO₂ and lactate levels in response to pRBC transfusion did not correlate with pretransfusion Hb. Our findings question the usefulness of SvO₂ and lactate levels as physiologic transfusion triggers to guide transfusion practice in cardiac surgery patients. TRIAL REGISTRATION: Johannes Kepler University Ethics Committee Study Reference Number 1063/2023.

Background: Critical care delivery in the emergency department (ED) may improve selected patient- and system-relevant outcomes. However, it remains unclear which organisational models to deliver critical care in the ED (CC-ED) have been implemented and what their outcome effects are. Methods: We conducted a systematic review and meta-analysis including studies describing organisational approaches to deliver CC-ED. Delivery models were categorised and described qualitatively. For studies reporting comparable outcomes, random-effects meta-analysis was performed to estimate pooled effects and 95% confidence intervals. Outcomes included mortality, intensive care unit (ICU) admission rates, ICU length of stay (LOS), hospital LOS, and cost of care. Results: Of 4,967 records, 67 were included into the qualitative assessment and 11 studies into the quantitative analysis, respectively. We identified five models to deliver CC-ED. These consisted of dedicated critical care areas in the ED ( n = 49/67, 73.1%), placement of critical care staff in the ED ( n = 5/67, 7.5%), deployment of critical care teams to the ED ( n = 5/67, 7.5%), telemedical support of ED staff by critical care teams ( n = 5/67, 7.5%), and implementation of protocols to accelerate ICU admission ( n = 3/67, 4.5%). Mortality was not different versus usual care in any of the CC-ED models. CC-ED models had variable effects on the ICU admission rate, hospital and ICU LOS. Dedicated critical care areas in the ED were associated with lower ICU admission rates [OR 0.83 (0.76–0.91), p < 0.001], and shorter hospital LOS [mean difference − 0.31 (-0.59 to -0.03) days, p = 0.03], but longer ICU LOS [mean difference 0.45 (0.31–0.6) days, p < 0.001]. Reported cost of care did not differ between CC-ED and usual care. Conclusions: We identified five different organisational model categories to deliver CC-ED. Dedicated critical care areas such as ED-ICUs was the model category most frequently published. Our quantitative meta-analysis suggests that compared with other CC-ED delivery models, dedicated critical care areas in the ED may reduce both ICU admission rates and hospital LOS of critically ill ED patients.

Background: ECMO-associated coagulopathy is a common phenomenon in patients undergoing ECMO therapy. However, data on coagulation trajectories in the post ECMO decannulation period are limited. This study aimed to explore changes in coagulatory function within 72 h after weaning of ECMO therapy. Methods: Exploratory, nested cohort study of a prospective, observational, single-centre cohort study investigating haemostatic changes in adult patients undergoing ECMO therapy at a tertiary academic centre and ECMO referral facility in Linz/Austria. Coagulation tests as well as ROTEM ^® analyses were performed at the time of ECMO decannulation (d0) and three days later (d3). Intra-individual changes in coagulation parameters and viscoelastic test results after weaning of ECMO therapy were determined using paired comparisons (Student’s t -tests or Wilcoxon signed-rank tests) between the two timepoints. Results: 30 adult patients were included into the final analysis. Platelet counts [97 (82–149) vs. 211 (161–346) G/L, p < 0.001)], Factor VIII activity [294 (208–427) vs. 400 (304–450) %, p = 0.03] and Factor XIII activity [63 (52–73) vs. 86 (70–96) %, p < 0.001] increased significantly between d0 and d3. Fibrinogen levels trended upwards after decannulation [601 (419–711) vs. 650 (495–790) mg/dL, p = 0.08]. Antithrombin activity [96 (83–117) vs. 111 (93–130) %, p = 0.001], Protein C [83 (69–99) vs. 93 (90–104) %, p = 0.01] and Protein S activity [78 (60–91) vs. 80 (72–103), p = 0.002] significantly increased between the two timepoints. D-Dimer levels significantly declined between d0 and d3 [13.5 [6–29] vs. 8.1 (3.9–17.3) %, p = 0.019]. ROTEM ^® analyses showed significant decreases in INTEM ^® coagulation time and clot formation time, and significant increases in clot amplitude at five and ten minutes, as well as maximum clot firmness in the INTEM ^® and EXTEM ^® assays between d0 and d3. Conclusions: Extensive changes in coagulation profiles were observed within 72 hours following ECMO weaning and decannulation. These changes reflect a rapid restoration of haemostasis and possibly an early shift towards a prothrombotic phenotype.

Background: Data on management and outcomes of critically ill emergency patients with a limitation of intensive care unit (ICU) admission are. We investigated critical care delivery, process measures and patient outcomes in patients with a documented limitation of ICU admission treated in a Critical Care Resuscitation Unit (CCRU). Methods: Retrospective, single-centre study including adult, non-traumatic emergency patients admitted to the CCRU of a tertiary academic hospital between October 2022 and April 2025. Patients were included if a decision not to proceed with ICU admission had been documented before or during CCRU care. Data were extracted from electronic medical records. The primary study objective was to determine survival and discharge outcomes, symptom-control interventions, and goals-of-care discussions and documentation. Associations with in-hospital and 28-day mortality were evaluated using Firth penalized logistic regression. Results: Among 1,294 CCRU admissions during the study period, 139 patients (10.7%) had a documented limitation of ICU admission. Ten patients (7.2%) were considered to have entered the irreversible dying process at CCRU admission, while 129 patients (92.8%) received a time-limited episode of critical care. Discussions with patients and families about goals of care were held in 24 [17.3% (95% CI, 11.4–24.6%)] and 88 [63.3% (95% CI, 54.7–71.3%)] patients, respectively. Goals of care were defined and documented in 135 of 139 [97.1% (95% CI, 94.3–99.9%)] subjects. Seventy-four patients [53.2% (95% CI, 45.0–61.3%)] survived to hospital discharge. At 28 days, 58 of 124 patients with available survival status were alive [46.8% (95% CI, 38.0-55.6%)]. Of 46 hospital survivors who had lived at home before CCRU admission, 36 (78.3%) returned home. Higher SOFA scores at CCRU admission were associated with in-hospital mortality [adjusted OR, 1.50 (95% CI, 1.26–1.85); p < 0.001] and 28-day mortality [adjusted OR, 1.44 (95% CI, 1.20–1.78); p < 0.001]. Conclusions: Among critically ill emergency patients with a documented limitation of ICU admission, CCRU care combined time-limited episodes of critical care with goals-of-care determination and symptom-directed or palliative care. More than half of patients survived to hospital discharge, and most survivors who had previously lived at home returned home.