Background: Mechanical complications remain common with the placement of peripherally inserted central catheters (PICCs), particularly in critically ill patients. Given the need to minimise procedural complications, strategies for reducing bleeding during PICC placement are essential. This study evaluated the efficacy of a previously introduced two-stage technique in minimising insertion-related bleeding compared with the traditional modified Seldinger technique in ICU patients. Methods: This study included 86 patients who underwent 92 PICC placements in the ICU of a tertiary university medical centre, between August 2022 and January 2025. Bleeding outcomes were assessed at three time points: 5 min, 30 min and within 24 h after insertion. Blood loss was evaluated semi-quantitatively based on the extent of gauze pad contamination. Results: In total, 56 were performed using the two-stage technique and 36 using the traditional method. Baseline characteristics were comparable between the two groups. Bleeding incidence was significantly lower in the two-stage group at all time points. At 5 min post-insertion, 93% of the patients in the two-stage group had no visible or only minimal bleeding compared to 28% in the traditional group. At 30 min, 84% had no visible or only minimal bleeding compared with 14% ( p < 0.001). In multivariate analysis, the two-stage technique was independently associated with a reduced bleeding risk (OR, 0.019; 95% CI, 0.005–0.074; p < 0.001). An interaction analysis showed that aPTT significantly modified the association between technique and bleeding (OR, 20.519; 95% CI, 1.643–255.851; p < 0.001). Conclusions: The modified two-stage technique appears to be a feasible alternative to conventional PICC placement and was associated with reduced insertion-related bleeding in ICU patients. The technique also resulted in fewer dressing changes within 24 h, suggesting more stable haemostasis and potential improvements in ICU care quality.

Background: The microbiological landscape and infection-source profiles of severe sepsis in Asian ICUs differ markedly from Western cohorts and may influence the effectiveness and prognosis of adjunctive therapies such as polymyxin B hemoperfusion (PMX-HP). However, real-world data on how pathogen categories, multidrug resistance (MDR), and infection sources affect outcomes in PMX-HP-treated patients are lacking. Methods: We conducted a retrospective cohort study in a tertiary medical ICU in Taiwan, including adult patients with severe sepsis or septic shock who received PMX-HP between 2013 and 2019. Microbiological data, infection sources, MDR profiles, organ support requirements, vasoactive–inotropic score (VIS), and mortality outcomes were retrieved from electronic records. Pathogen groups (Gram-negative, Gram-positive, fungal, no-growth), MDR status, and infection sources were analyzed for associations with 28-day, ICU, and hospital mortality. Results: Among 64 patients (mean age 66.1 years; 67.2% male), Gram-negative pathogens predominated (70.3%), with Escherichia coli (31.3%) and Klebsiella pneumoniae (21.9%) being the most frequently identified organisms. MDR organisms were isolated in 26.6% of patients. The most common infection sources were pneumonia (29.7%), intra-abdominal infection (18.8%), and urinary tract infection (17.2%). Gram-negative infections were associated with higher CRRT utilization (71.9% vs. 47.1%, p = 0.04) and higher VIS at 24 h. MDR status was significantly associated with early CRRT requirement (64.7% vs. 38.6%, p = 0.048), but not with 28-day mortality (52.9% vs. 43.2%, p = 0.42). No infection source was independently associated with mortality after adjustment for APACHE II, CRRT, and VIS. Instead, greater organ failure severity—particularly renal failure requiring CRRT—was strongly associated with mortality in this cohort. Conclusions: In PMX-HP-treated severe sepsis patients, Gram-negative predominance and MDR status were associated with increased organ support requirements but were not independently associated with mortality. Outcomes were primarily associated with overall illness severity rather than microbiological category. These findings highlight the importance of combining microbiological data with dynamic physiological markers for prognostic risk stratification in Asian ICUs.

Lower-extremity peripherally inserted central catheters (PICCs) are used in critically ill adults when upper-extremity access is limited, yet real-world data on indications, dwell time, and device-related outcomes remain scarce. We retrospectively reviewed consecutive ultrasound-guided mid-thigh lower-extremity PICC placements performed under a standardized protocol (15 cm below the inguinal ligament; fixed 55-cm insertion depth) in an adult ICU and extracted indication patterns, catheter dwell time, removal reasons, and microbiological findings. Among 38 placements in 37 patients, difficult peripheral access was present in all cases; prolonged intravenous antibiotics were the predominant indication (34/38, 89.5%), followed by total parenteral nutrition (13/38, 34.2%) and vasopressor therapy (2/38, 5.3%). Median dwell time was 19.5 days (IQR 12–25; range 3–48). Catheters were most commonly removed due to death (15/38, 39.5%), discharge (13/38, 34.2%), or no longer being clinically indicated (8/38, 21.1%), while removal for suspected catheter infection/fever occurred in 2/38 (5.3%). A catheter-drawn culture was positive in 1/38 (2.6%; Candida albicans), whereas peripheral blood cultures were positive in 4/38 (10.5%). In this single-center retrospective descriptive cohort, standardized mid-thigh lower-extremity PICCs were used for prolonged venous access. Removals for suspected infection/fever evaluation were uncommon; however, CRBSI was not adjudicated and thrombosis surveillance was not performed. These findings describe local utilization patterns and support future comparative studies and stewardship-focused quality improvement.

Major reconstructive free-flap surgery often requires ICU admission, yet early signals associated with postoperative antibiotic escalation remain poorly characterized. We conducted a single-center retrospective cohort study of 119 consecutive postoperative ICU admissions after major free-flap reconstruction. Exposures were postoperative day-1 procalcitonin (PCT) and documented postoperative shock; the primary endpoint was clinician-initiated antibiotic escalation (“upgrade”), and secondary endpoints were documented microbiological positivity and ICU mechanical ventilation duration. Escalation occurred in 85/119 admissions (71.4%). Day-1 PCT was higher with escalation (median 0.25 vs. 0.135 ng/mL; p = 0.033), and shock was more frequent (59/85 [69.4%] vs. 13/34 [38.2%]; p = 0.003). Escalation was associated with longer ventilation (median 3515 vs. 2170 min; p < 0.001) and higher rates of any positive culture (54/85 [63.5%] vs. 8/34 [23.5%]; p < 0.001). In multivariable logistic regression adjusting for operative time and intraoperative IV volume, shock remained independently associated with escalation (adjusted OR 3.52, 95% CI 1.48–8.36; p = 0.004), whereas log-transformed PCT was not (p = 0.224). PCT showed modest apparent discrimination for escalation (AUC 0.63), improving to 0.71 when combined with shock. These findings should be interpreted as observational associations with escalation behavior, supporting prospective evaluation of physiology-plus-biomarker stewardship approaches.

Background: Drug-induced sleep endoscopy (DISE) with a jaw-thrust maneuver is used to simulate mandibular advancement in obstructive sleep apnea (OSA), yet determinants of functional airway improvement remain incompletely defined. Objective: To identify clinical, polysomnographic, and baseline DISE anatomic factors associated with jaw-thrust responsiveness. Methods: We conducted a single-center retrospective observational study of adults with polysomnography-confirmed OSA who underwent DISE with paired baseline and jaw-thrust VOTE assessments between 1 January 2015 and 31 December 2025 (n = 355). Jaw-thrust responsiveness was defined a priori as a within-subject reduction in the number of obstructed VOTE sites (grade ≥ 1). Multivariable logistic regression was used to identify independent correlates within a prespecified explanatory modeling framework. The study was approved by the Institutional Review Board of Taipei Tzu Chi Hospital (protocol 14-IRB079), with the need for informed consent being waived. Results: Jaw thrust reduced overall obstruction burden from two (two to three) to one (one to two) sites (Wilcoxon p < 0.001). Hypopharyngeal levels demonstrated the greatest improvement, particularly at the tongue base (39.2% to 7.6%) and epiglottis (23.9% to 5.4%) (both p < 0.001). Overall, 62.8% met responder criteria and 18.9% achieved complete normalization. In multivariable analysis (n = 272), baseline tongue-base collapse (adjusted odds ratio [aOR] 2.46, 95% CI 1.20–5.04) and greater baseline multilevel obstruction burden (aOR 1.85 per SD, 95% CI 1.19–2.85) were independently associated with responsiveness, whereas conventional PSG severity metrics were not. Conclusions: In adults with OSA, jaw-thrust responsiveness during DISE is more strongly associated with baseline anatomic phenotype than with global PSG severity. Standardized DISE functional assessment may provide complementary information to support phenotype-informed selection of non-CPAP therapies, pending prospective validation.

First-24-hour hypernatremia–hyperkalemia co-occurrence may mark severe illness, but its incremental prognostic value is uncertain. We analyzed 13,383 adult ICU admissions (11,942 patients) in Taiwan during 2018–2020. Peak sodium > 145 and potassium > 5.5 mmol/L defined four phenotypes; peaks need not be simultaneous. This prognostic association analysis used information accumulated during the first ICU day. Patient-clustered logistic regression compared total APACHE II adjustment with complementary adjustment excluding its sodium/potassium points. Twenty repeated patient-grouped five-fold cross-validations assessed discrimination. Thirty-day mortality was 12.2%, 33.7%, 32.7%, and 74.4% in the neither (n = 12,097), hypernatremia-only (n = 841), hyperkalemia-only (n = 367), and co-occurrence (n = 78) groups. With total APACHE II, the co-occurrence odds ratio was 1.90 (95% CI 1.07–3.39), global phenotype P = 0.094, and mean AUC change 0.00007. With component-excluded adjustment, the corresponding odds ratio was 2.70 (1.53–4.75), global P = 0.002, and mean AUC change 0.00037. Additional sensitivity analyses examined outcome availability, in-hospital mortality, sparse data, and alternative thresholds. Outcome missingness and unavailable measurement/death timing limit interpretation. Co-occurrence characterized a small high-risk subgroup, but incremental discrimination was negligible; causality and clinical predictive utility were not established.