Cardiogenic shock secondary to acute myocardial infarction complicated by mechanical failure remains associated with high mortality despite advances in cardiac surgery and mechanical circulatory support. We report the case of a 42-year-old patient with posterior papillary muscle rupture leading to severe mitral regurgitation, managed with emergency surgical intervention and extracorporeal membrane oxygenation. The patient, with a history of Type I Bipolar Disorder under long-term lithium therapy and chronic Cannabis use, presented in critical condition with cardiogenic shock (Killip IV), acute pulmonary edema, and ST-segment elevation myocardial infarction in the infero-posterior territory. Coronary angiography revealed right coronary artery occlusion and involvement of an obtuse marginal branch. Emergency mitral valve replacement with a mechanical prosthesis and aortocoronary bypass were performed. Due to failure to wean from cardiopulmonary bypass, central veno-arterial ECMO was initiated. The postoperative course was complicated by hemodynamic instability and recurrent pericardial collections requiring repeated surgical interventions and conversion to peripheral ECMO. Multiorgan dysfunction developed, including hepato-renal failure requiring hemofiltration, neurological injury, respiratory impairment, and neuropsychiatric complications. Despite these challenges, progressive recovery was achieved under intensive multidisciplinary management. This case emphasizes the importance of early surgical correction and tailored ECMO support in managing post-infarction mechanical complications.

Drug dosing during continuous renal replacement therapy (CRRT) is difficult in critically ill patients because drug exposure is influenced by both the patient and the extracorporeal treatment. This narrative review provides a practical overview of drug dosing during CRRT, while intermittent hemodialysis and sustained low-efficiency dialysis are discussed only where they provide relevant contextual or comparative information. It summarizes the main drug-related, patient-related, and treatment-related factors that influence extracorporeal drug clearance and discusses their clinical implications for commonly used drug classes. Loading and maintenance doses should be considered separately: loading doses depend mainly on volume of distribution and the need for early therapeutic exposure, whereas maintenance dosing depends on total clearance, including residual renal, extracorporeal, and non-renal clearance. Therapeutic drug monitoring can help guide dose adjustment when validated targets are available, while model-informed precision dosing may provide additional support in selected patients. The review also proposes an eight-step practical framework based on residual kidney function, the actual delivered CRRT prescription, drug pharmacokinetics and pharmacodynamics, therapeutic monitoring, and repeated reassessment. Future approaches may combine real-time CRRT data with pharmacokinetic models to support more individualized dosing.

Cardiogenic shock secondary to acute myocardial infarction complicated by mechanical failure remains associated with high mortality despite advances in cardiac surgery and mechanical circulatory support. We report the case of a 42-year-old patient with poste-rior papillary muscle rupture leading to severe mitral regurgitation, managed with emergency surgical intervention and extracorporeal membrane oxygenation. The pa-tient, with a history of Type I Bipolar Disorder under long-term lithium therapy and chronic Cannabis use, presented in critical condition with cardiogenic shock (Killip IV), acute pulmonary edema, and ST-segment elevation myocardial infarction in the in-fero-posterior territory. Coronary angiography revealed right coronary artery occlusion and involvement of an obtuse marginal branch. Emergency mitral valve replacement with a mechanical prosthesis and aortocoronary bypass were performed. Due to failure to wean from cardiopulmonary bypass, central veno-arterial ECMO was initiated. The postoperative course was complicated by hemodynamic instability and recurrent peri-cardial collections requiring repeated surgical interventions and conversion to periph-eral ECMO. Multiorgan dysfunction developed, including hepato-renal failure requiring hemofiltration, neurological injury, respiratory impairment, and neuropsychiatric complications. Despite these challenges, progressive recovery was achieved under in-tensive multidisciplinary management. This case emphasizes the importance of early surgical correction and tailored ECMO support in managing post-infarction mechanical complications.

Critically ill patients frequently move between the intensive care unit (ICU) and the operating room while remaining dependent on ventilatory, hemodynamic, antimicrobial, sedative, analgesic, and renal support. Although extensive perioperative data are generated, clinically relevant information may remain fragmented across devices and electronic systems. This narrative review synthesizes the literature published primarily between 2016 and 2026 on perioperative digital continuity, structured ICU–operating room handoff, interoperability, artificial intelligence (AI)-supported decision support, continuous renal replacement therapy (CRRT)-related pharmacokinetic personalization, and digital twin concepts. Based on this synthesis, we develop a conceptual framework in which the Intelligent Operating Room and Smart ICU function as connected clinical information nodes. The framework is organized around a minimum perioperative continuity dataset, a perioperative delta view, and the author-proposed concept of Time-to-Truth at ICU readmission. Current evidence supports structured handoff and selected AI-assisted physiological prediction, but evidence for improvement in major patient-centered outcomes remains limited and heterogeneous. CRRT illustrates the importance of preserving information on delivered therapy, interruptions, residual kidney function, and treatment-related changes when interpreting drug exposure. The proposed framework is not clinically validated and is intended as a basis for future implementation and prospective evaluation. Overall, the review suggests that improving digital continuity should precede more complex forms of automation in perioperative critical care.