Ventilator-associated pneumonia (VAP) is a prevailing nosocomial infection in critically ill patients requiring invasive mechanical ventilation (iMV). The impact of VAP is profound, adversely affecting patient outcomes and placing a significant burden on healthcare resources. This study assessed for the first time the contemporary VAP epidemiology in Portugal and its burden on the healthcare system and clinical outcomes. Additionally, resource consumption (duration of iMV, intensive care unit (ICU), hospital length of stay (LOS)) and empirical antimicrobial therapy were also evaluated. This multicenter, retrospective study included patients admitted to the hospital between July 2016 and December 2017 in a participating ICU, who underwent iMV for at least 48 h. Patients with a VAP diagnosis were segregated for further analysis (n = 197). Control patients, ventilated for >48 h but without a VAP diagnosis, were also included in a 1:1 ratio. Cumulative VAP incidence was computed. All-cause mortality was assessed at 28, 90, and 365 days after ICU admission. Cumulative VAP incidence was 9.2% (95% CI 8.0–10.5). The all-cause mortality rate in VAP patients was 24.9%, 34.0%, and 40.6%, respectively, and these values were similar to those observed in patients without VAP diagnosis. Further, patients with VAP had significantly longer ICU (27.5 vs. 11.0 days, p < 0.001) and hospital LOS (61 vs. 35.9 days, p < 0.001), more time under iMV (20.7 vs. 8.0 days, p < 0.001) and were more often subjected to tracheostomy (36.5 vs. 14.2%; p < 0.001). Patients with VAP who received inappropriate empirical antimicrobials had higher 28-day mortality, 34.3% vs. 19.5% (odds ratio 2.16, 95% CI 1.10–4.23), although the same was not independently associated with 1-year all-cause mortality (p = 0.107). This study described the VAP impact and burden on the Portuguese healthcare system, with approximately 9% of patients undergoing iMV for >48 h developing VAP, leading to increased resource consumption (longer ICU and hospital LOS). An unexpectedly high incidence of inappropriate, empirical antimicrobial therapy was also noted, being positively associated with a higher mortality risk of these patients. Knowledge of the Portuguese epidemiology characterization of VAP and its multidimensional impact is essential for efficient treatment and optimized long-term health outcomes of these patients.

(1) Background: Extracorporeal membrane oxygenation (ECMO) is a complex procedure affecting both the risk of thrombosis and bleeding. High-quality data to personalize anticoagulation management in ECMO are lacking, resulting in a high variability in practice among centers. For this reason, we review coagulation methods and monitoring and share a pragmatic proposal of coagulation management, as performed in our high-volume ECMO Referral Centre; (2) Methods: We revised the anticoagulation options and monitoring methods available for coagulation management in ECMO through PubMed search based on words including “anticoagulation,” “coagulation assays,” “ECMO,” “ELSO,” and “ISTH”; (3) Results: Actual revision of the literature was described as our routine practice regarding ECMO anticoagulation and monitoring; (4) Conclusions: No coagulation test is exclusively predictive of bleeding or thrombotic risk in patients undergoing ECMO support. An approach that allows for a tailored regimen of anticoagulation (regardless of agent used) and monitoring is mandatory. To accomplish this, we propose that the titration of anticoagulation therapies should include multiple laboratory tests, including anti-Xa, aPTT, ACT, viscoelastic tests, AT levels, platelet count, fibrinogen, and FXIII levels. Anticoagulation regimens should be tailored to a specific patient and personalized based on this complex array of essays.

Introduction: COVID-19-associated coagulopathy includes systemic and endothelial inflammation with coagulation dysregulation related to immunothrombosis. The aim of this study was to characterize this complication of SARS-CoV-2 infection in patients with moderate to severe COVID-19. Methods: An open-label, prospective observational study conducted in patients with COVID-19 moderate to severe acute respiratory failure admitted to an intensive care unit (ICU). Coagulation testing, including thromboelastometry, biochemical analysis and clinical variables, were collected at prespecified time points during the 30 days of ICU stay.Results: The study included 145 patients, 73.8% male, with a median age of 68 years (interquartile range - IQR 55 - 74). The most prevalent comorbidities were arterial hypertension (63.4%), obesity (44.1%) and diabetes (22.1%). Simplified acute physiology score II (SAPS II) was on average 43.5 (11 - 105) and sequential organ failure assessment (SOFA) at admission was 7.5 (0 - 14). During ICU stay, 66.9% of patients underwent invasive mechanical ventilation and 18.4% extracorporeal membrane oxygenation support; thrombotic and hemorrhagic events occurred in 22.1% and 15.1% of the patients respectively; anticoagulation with heparin was present in 99.2% of patients since early ICU stay. Death occurred in 35% of patients. Longitudinal studies revealed changes in almost all coagulation tests during the ICU stay. SOFA score, lymphocyte counts, some biochemical, inflammatory and coagulation parameters, including hypercoagulability and hypofibrinolysis seen in thromboelastometry, differed significantly (p < 0.05), between ICU admission and discharge. Hypercoagulability and hypofibrinolysis persisted throughout ICU hospitalization, showing higher incidence and severity in non-survivors.Conclusion: COVID-19-associated coagulopathy is characterized by hypercoagulability and hypofibrinolysis from ICU admission, and persisted throughout the clinical course in severe COVID-19. These changes were more pronounced in patients with higher disease burden and in non-survivors.

Background and Aim: New-onset atrial fibrillation (NOAF) is a common condition in critically ill patients, yet the evidence on optimal NOAF management and outcomes is limited. This study evaluates the impact of management strategies on short- and long-term outcomes in patients who develop NOAF during their intensive care unit (ICU) stay. Methods: A retrospective, single-centre study was conducted of all patients with NOAF admitted in a multidisciplinary ICU between 2020 and 2023. The clinical characteristics and outcomes of the patients were collected. The endpoints included the characterisation of management strategies, short-term outcomes during ICU stays (including atrial fibrillation [AF] recurrence), and long-term outcomes after discharge (including AF recurrence and a composite of death or cardiovascular hospitalisation). Results: A total of 160 patients developed NOAF (mean age 69.5 ± 11.8 years; 63% male). Most had cardiovascular comorbidities and high illness severity, with frequent mechanical ventilation (87%) and vasopressor (89%) use. Rhythm-control strategies—predominantly amiodarone—were associated with lower in-hospital AF recurrence (OR 0.28, p = 0.044) and a numerical reduction in post-discharge recurrence. Anticoagulation was initiated in 45% of patients and continued at discharge in 44%, without major bleeding. ICU and in-hospital mortality were 33% and 43%, respectively. During a median follow-up of 10 (range 0–56) months, post-ICU discharge AF recurrence occurred in 34% of patients initially discharged in sinus rhythm. Anticoagulation at discharge was not associated with recurrence, while rhythm control in the ICU and absence of in-hospital recurrence strongly predicted reduced post-discharge recurrence (p < 0.001). Nine patients required readmission, mainly for heart failure or ischaemic stroke. The composite long-term outcome occurred in 24 patients (27%). Conclusions: Post-ICU discharge AF recurrence after NOAF was common. Early rhythm-control strategies were associated with lower in-hospital and post-discharge AF recurrence, and individualised anticoagulation appeared safe in this observational cohort. These findings support proactive post-ICU monitoring and risk-adapted management strategies.

Introduction: Ventilator-associated pneumonia (VAP) is associated with increased morbidity and mortality. Early-onset (EOVAP) and late-onset (LOVAP) VAP differ in risk factors, microbiology, and outcomes. Methods: A retrospective cohort study of adult ICU patients admitted to a tertiary hospital between May 2020 and May 2022 compared EOVAP and LOVAP. Results: 194 patients were included (73.7% male), with a median age of 61 years. A total of 70.6% were admitted to the ICU for infection-related respiratory failure, predominantly due to COVID-19 (59.3%). EOVAP represented 21% and LOVAP 79% of cases, with median days to diagnosis of 4 and 11, respectively. Empirical antibiotic therapy was adequate in both groups; de-escalation was possible in 26.8%, and escalation due to treatment failure was required in 13.4%. The most commonly prescribed initial antibiotic was piperacillin–tazobactam (45%). Broad-spectrum antibiotic use did not differ between groups. Amoxicillin–clavulanate resistance was high in both groups (LOVAP 62.1%; EOVAP 48.8%), and piperacillin–tazobactam resistance was more frequent in LOVAP (41.2%). Follow-up cultures showed a high persistence rate (73.2%), with no significant change in resistance patterns. Conclusions: VAP remains common in the ICU, and the COVID-19 pandemic significantly impacted the already complex epidemiology of VAP. High resistance rates to amoxicillin–clavulanate and frequent isolation of MDR pathogens challenge empirical treatment based on onset timing, supporting empiric antibiotic selection guided by local microbiological ecology.

INTRODUCTION: Intensive care unit (ICU) admission and multi-organ support is fundamental in a subset of patients with hematologic malignancies and severe illnes