Introduction: Treatment of sepsis and septic shock can be a challenge even for intensive care units (ICUs) in high income countries, but it is especially difficult for ICUs with limited resources. Aim: To evaluate the impact of CERTAIN on treatment of critically ill septic patients in low-resource medical ICU. Materials and Methods: In a before-and-after study design, we compared clinical outcomes, processes, and complications (hospital acquired infections) 1 year before and 2 years after (2016 and 2017) introduction of CERTAIN. Results: A total of 125 patients with sepsis were prospectively identified for a 3-year period. Mean patient age, gender distribution, number of patients on mechanical ventilation (33 [76.7%] vs. 42 [84%] vs. 24 [75%]) and vasopressor use (23 [53.5%] vs. 34 [68%] vs. 24 [75%]) were similar before (2015) and 2 years after (2016 and 2017) the implementation of CERTAIN. Severity of illness (Simplified Acute Physiology Score II [SAPS II score]) was higher after the implementation. The checklist was incorporated in the daily practice with 100% adherence to its use. The duration of mechanical ventilation (5.3 ± 5.3 vs. 4.2 ± 3.6 vs. 3.7 ± 5.5), antibiotic treatment (8.2 ± 5.4 vs. 6.9 ± 4.1 vs. 5.8 ± 5.6), central venous catheter use (6.2 ± 5.7 vs. 5.7 ± 4.6 vs. 4.2 ± 6.1), ICU stay (8.4 ± 5.4 vs. 7.1 ± 4.1 vs. 5.8 ± 5.6), and the incidence of nosocomial infection (33.3% vs. 30% vs. 12.5%) decreased in the period after the onset of the intervention, but the results did not reach statistical significance. When adjusted for baseline characteristics, CERTAIN was not associated with hospital mortality (odds ratio 0.88, 0.38–2.04). Conclusion: CERTAIN was readily adopted in the ICU workflow and was associated with improvement in treatment of critically ill patients with sepsis.

Background and Objectives: Coronavirus disease 2019 (COVID-19) is a novel infectious disease that has spread worldwide. As of 5 March 2020, the COVID-19 pandemic has resulted in approximately 111,767 cases and 6338 deaths in the Republic of Srpska and 375,554 cases and 15,718 deaths in Bosnia and Herzegovina. Our objective in the present study was to determine the characteristics and outcomes of critically ill pregnant/postpartum women with COVID-19 in the Republic of Srpska. Materials and Methods: The retrospective observational study of prospectively collected data included all critically ill pregnant/postpartum women with COVID-19 in a university-affiliated hospital between 1 April 2020 and 1 April 2022. Infection was confirmed by real-time reverse transcriptase polymerase chain reaction (RT-PCR) from nasopharyngeal swab specimens and respiratory secretions. Patients’ demographics, clinical and laboratory data, pharmacotherapy, and neonatal outcomes were analysed. Results: Out of the 153 registered pregnant women with COVID-19 treated at the gynaecology department of the University Clinical Centre of the Republic of Srpska, 19 (12.41%) critically ill pregnant/postpartum women (median age of 36 (IQR, 29–38) years) were admitted to the medical intensive care unit (MICU). The mortality rate was 21.05% (four patients) during the study period. Of all patients (19), 14 gave birth (73.68%), and 4 (21.05%) were treated with veno-venous extracorporeal membrane oxygenation (vvECMO). Conclusions: Fourteen infants were born prematurely and none of them died during hospitalisation. A high mortality rate was detected among the critically ill pregnant/postpartum patients treated with mechanical ventilation and vvECMO in the MICU. The preterm birth rate was high in patients who required a higher level of life support (vvECMO and ventilatory support).

Background: Patients undergoing prolonged mechanical ventilation commonly require tracheotomy. The main aim of this study was to evaluate the outcomes of tracheotomy for patients with acute respiratory distress syndrome (ARDS) associated with COVID-19 in low-resource settings. Methods: A retrospective, single-center, observational cohort study was performed on patients with ARDS associated with COVID-19. Patients who underwent intubation alone were compared with those who received both intubation and subsequent tracheotomy. The analysis included patient demographics, comorbidities, and outcomes. Results: Patients undergoing tracheotomy (n = 89) were compared with intubated patients (n = 622). The median time from intubation to tracheotomy was 10 days (IQR: 6–15 days). Overall, 608 patients (85.5%) died in the hospital. Thirty-seven patients (35.9%) in the survival group had tracheostomy compared with fifty-two patients (8.5%) in the non-survival group (p < 0.001). The Kaplan–Meier curve shows a higher probability of survival in the tracheotomy group compared with the non-tracheotomy group (log-rank test: p < 0.001). Tracheotomy was found to be independently associated with lower in-hospital mortality (HR = 0.16 [95% CI: 0.11–0.23], p < 0.001) in the multivariable Cox proportional hazards regression analysis after adjusting for potential confounding factors. Furthermore, tracheotomy was associated with a higher cumulative incidence of being alive and off the ventilator at day 28 (SHR = 2.87 [95% CI: 1.88–4.38], p < 0.001). Conclusions: Tracheotomy was associated with reduced in-hospital mortality and longer ventilator-free days.

A 38-year-old male patient was admitted to the Medical Intensive Care Unit during the second wave of the coronavirus disease (COVID-19) pandemic presenting with fever, headache, muscle pain, and cough. The low-dose chest computed tomography (CT) result was normal, but an increased serum level of procalcitonin (PCT) was detected. Due to COVID-19, pronounced symptoms, and increased inflammatory markers, empiric antibiotic therapy was started. PCT level remained elevated despite 7 days of antimicrobial treatment. Hence, the diagnostic evaluation of the patient was expanded, and we identified medullary thyroid microcarcinoma. After diagnosis, a total thyroidectomy with cervical lymph node resection was performed, and the patient was discharged with oral levothyroxine. Control measurements of serum calcitonin and 18F-fluorodihydroxyphenylalanine positron emission tomography (18F-PET/CT) showed cervical and mediastinal lymph node metastases. Beside surgical treatment, the patient was not motivated for any adjuvant therapy and no new lesions were detected on control PET/CT two years after. In conclusion, clinicians should also consider malignancies such as medullary thyroid carcinoma as a potential cause of increased PCT levels, and as a next step should measure serum calcitonin level and perform neck ultrasound.

Acute respiratory distress syndrome (ARDS) is a severe clinical condition characterized by acute respiratory failure and a high mortality risk despite conventional mechanical ventilatory support. Veno-venous extracorporeal membrane oxygenation (vvECMO) has emerged as an effective life-support technology for patients with ARDS. However, complications may arise following the decannulation of vvECMO, with a relatively frequent development of systemic hyperinflammation (SHI). Among the various treatment strategies for SHI, the use of hemoadsorption with CytoSorb^® has shown promising results in removing excessive levels of cytokines and attenuating the hyperinflammatory response. In this case series, we present three critically ill patients with ARDS secondary to pneumonia who underwent vvECMO and subsequently received prophylactic hemoadsorption with CytoSorb^® following decannulation as a part of our clinical practice. This case series aims to describe the potential positive effects of hemoadsorption in preventing the development of SHI after vvECMO decannulation in ARDS patients.

Introduction Sepsis is one of the leading causes of ICU admissions, with a substantial proportion of patients developing sepsis-associated acute kidney injury (S-AKI). In such cases, continuous renal replacement therapy (CRRT) is a cornerstone of renal supportive care; however, evidence from low-resource settings (LRS) remains limited. This study aimed to describe the demographic and clinical characteristics of patients with S-AKI treated with CRRT in an LRS medical ICU (MICU), as well as to identify predictors of mortality. Subjects and methods This retrospective, observational, consecutive, single-center study included adult patients admitted to the MICU between June 1, 2023, and June 1, 2024, with a diagnosis of sepsis complicated by S-AKI, and managed with CRRT. Statistical analyses were conducted using the Mann-Whitney U and Pearson χ² tests, and multinomial logistic regression was used to identify independent predictors of mortality. ORs were reported for key predictors, and Kaplan-Meier survival analysis was performed to assess time to event. Results A total of 96 patients with S-AKI were treated with CRRT (65 male patients, median age 64.5 years). The 28-day all-cause mortality rate was 69.8%, with a high rate of septic shock at admission among nonsurvivors (n=49, p= 0.019). Kaplan-Meier analysis demonstrated a median survival of 12 days (95%CI: 8.95-15.05). The majority of patients were admitted from hospital wards (n=59), and the most common comorbidities were hypertension (n=63), diabetes (n=38), and cardiomyopathy (n=27). Survivors had a longer MICU length of stay (p= 0.003). Nonsurvivors had a higher initial Sequential Organ Failure Assessment and Simplified Acute Physiology Score II (SAPS II) scores at MICU admission (p< 0.000), and prominent abnormalities at CRRT initiation for albumin (p= 0.004), troponine I (p= 0.032), and lactate (p= 0.004). Invasive mechanical ventilation and vasopressor therapy were predominantly used among nonsurvivors (p< 0.001). Continuous Venovenous Hemodiafiltration (CVVHDF) was the CRRT modality used for all patients (three patients used a combination of continuous and intermittent techniques), and hemoadsorption filters were used in 38 patients. The preferential indications for CVVHDF included anuria and profound metabolic acidosis, either in combination (n=51) or alone (n=17 and n=22). The most common sources of sepsis were pneumonia (n=42), urinary tract infection (n=13), multiple site infection (n=11), and abdomen (n=11). At MICU admission, blood cultures were positive in 34 patients (21 with gram-positive bacteria), urine cultures in 21 patients (12 with gram-negative bacteria), and tracheal aspirate/bronchoalveolar lavage in 39 patients (26 with gram-negative bacteria). Among the patients, 10 had a concurrent viral infection, six had candidiasis, and three had aspergillosis. Logistic regression identified an association between poor outcome and SAPS II at MICU admission (OR=1.07; 95%CI: 1.03-1.12), albumin (OR=0.89; 95%CI: 0.81-5.63), and vasopressor therapy (OR= 8.36; 95%CI: 1.51-46.33) at CRRT initiation. Conclusion Patients with S-AKI requiring CRRT represent a particularly vulnerable subgroup with a high risk of poor outcomes, especially when presenting with septic shock. In this single-center, low-resource MICU study, independent predictors of mortality were a high SAPS II score at MICU admission, as well as vasopressor requirement and hypoalbuminemia at CRRT initiation.