Jorge Iván Alvarado Sánchez

BACKGROUND: Optimal blood pressure management during endovascular therapy (EVT) for acute ischemic stroke remains uncertain. Intraprocedural hypotension may compromise cerebral perfusion and worsen neurological outcomes, yet existing evidence is inconsistent, and no prior meta-analysis has synthesized observational data on intraoperative hypotension during EVT. METHODS: We conducted a systematic review and meta-analysis of studies evaluating the association between intraoperative hypotension and outcomes in patients undergoing EVT for acute ischemic stroke. MEDLINE and Embase were searched from inception to May 2024 without language restrictions. Eligible studies enrolled adult patients undergoing EVT with reported intraoperative blood pressure data and prespecified clinical outcomes. The primary outcome was favorable functional outcome (modified Rankin Scale score, 0–2) at 90 days. Secondary outcomes included failure of reperfusion (Thrombolysis in Cerebral Infarction 2 =0%). No significant association was found between hypotension and failure of reperfusion (odds ratio, 1.36 [95% CI, 0.85–2.18]). Evidence regarding early neurological improvement was limited. Narrative synthesis indicated that greater cumulative exposure to hypotension correlated with larger final infarct volumes. Certainty of evidence was rated high for favorable functional outcome and low for failure of reperfusion. CONCLUSIONS: Intraoperative hypotension during EVT, defined as mean arterial pressure below 60 to 70 mm Hg or a relative decrease of ≥20% to 40% from baseline, is associated with worse 90-day functional outcomes, independent of reperfusion status. These findings support hemodynamic monitoring during EVT and suggest that intraoperative hypotension is associated with worse functional outcomes.

Restoring arterial pressure in hypotensive shock is a primary resuscitation goal, yet increases in cardiac output after fluid administration do not consistently produce meaningful increases in arterial pressure. This dissociation highlights the importance of understanding pressure–flow interactions during hemodynamic interventions. Dynamic arterial elastance (EaDyn) is a functional hemodynamic index proposed to characterize these interactions. Rather than reflecting static vascular resistance, EaDyn is hypothesized to describe the dynamic relationship between cardiac output and arterial load within the framework of ventriculo–arterial coupling. Clinically, EaDyn has been investigated as a predictor of the arterial pressure response to fluid administration in preload-responsive patients and as a marker of pressure stability during vasopressor reduction. However, current clinical evidence remains limited, heterogeneous, and derived largely from selected populations. This review summarizes the physiologic basis of EaDyn, critically appraises the available clinical evidence, and highlights current limitations and priorities for future research.

Maintaining mean arterial pressure (MAP) within a predefined target is central to haemodynamic management in surgical and critically ill adults receiving vasopressors. Closed-loop vasopressor (CLV) systems automate titration to optimise blood pressure control, but their clinical effectiveness remains uncertain. We performed a systematic review and meta-analysis comparing CLV with manual titration. This PRISMA 2020–compliant review was prospectively registered in PROSPERO (CRD420250655697). MEDLINE, Embase, Scopus, Web of Science, CENTRAL, and the Cochrane Library were searched (January 2000–June 2025). Randomised controlled trials enrolling adults receiving vasopressors in perioperative or intensive care settings were included. Primary outcomes were time within the MAP target range and time spent in hypotension or hypertension. Risk of bias was assessed using RoB 2.0 and certainty of evidence using GRADE. Random- or fixed-effects models were selected according to heterogeneity. Six randomized controlled trials (215 patients) were included in the systematic review, whereas five perioperative trials contributed to the meta-analysis of haemodynamic control outcomes, and one ICU-based study was summarized narratively because it did not report comparable MAP control endpoints. CLV increased time within the MAP target range (mean difference [MD] 33.94%, 95% CI 20.41–47.46; I ² = 77%) and reduced time in hypotension (MD − 18.24%, 95% CI − 28.95 to − 7.53; I ² = 73%). There was no significant difference in time in hypertension, cumulative norepinephrine dose, or major/minor adverse events. ICU length of stay was not pooled because of clinical and methodological heterogeneity. Certainty of evidence ranged from low to high (moderate for haemodynamic control outcomes). CLV systems improved haemodynamic control, primarily in perioperative settings, but heterogeneity and small samples limit confidence in effect size and generalisability. Evidence in critically ill populations remains limited, and larger trials are needed to determine whether improvements in these physiological surrogate endpoints translate into meaningful patient-centred outcomes.

Predicting fluid responsiveness in patients with acute respiratory distress syndrome (ARDS) remains a clinical challenge. While dynamic indices such as pul

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Background: Difficult weaning from mechanical ventilation remains a major challenge in intensive care units (ICUs), particularly among patients requiring prolonged respiratory support. High-flow tracheal therapy (HFTT) may improve gas exchange, humidification, and comfort in tracheostomized patients, but its clinical impact on weaning duration is uncertain. Methods: We conducted a retrospective cohort study including critically ill adult patients who underwent tracheostomy between 2020 and 2023. Patients received either HFTT or conventional oxygen therapy via tracheostomy mask. The primary outcome was post-tracheostomy mechanical ventilation duration, defined as the number of days from tracheostomy to successful ventilatory support withdrawal. Propensity score matching was performed using age, sex, Sequential Organ Failure Assessment (SOFA) score, presence of acute respiratory distress syndrome (ARDS), and sedation duration. Between-group comparisons employed parametric or nonparametric tests as appropriate, and a negative binomial regression model assessed potential associations with weaning duration. Results: Of 207 screened patients, 65 were included after matching (HFTT group = 19, tracheostomy mask group = 46). Baseline characteristics were balanced. The median post-tracheostomy weaning duration was 13 [8–19] days in the HFTT group and 11 [6–17] days in the tracheostomy mask group ( p = 0.47). Total mechanical ventilation time was longer in the HFTT group ( p = 0.02), but HFTT use was not associated with the post-tracheostomy weaning duration (β = 0.01 ± 0.22, p = 0.96). Conclusions: In this matched cohort, high-flow tracheal therapy did not shorten the weaning duration after tracheostomy compared with conventional oxygen therapy. Prospective studies are needed to clarify its optimal clinical role.

Background: Intensive care unit-acquired weakness (ICUAW) and post-intensive care syndrome (PICS) are significant complications among critically ill patients, leading to prolonged hospital stays, increased healthcare costs, and reduced quality of life. Early physical therapy in the ICU has shown promise in mitigating these adverse outcomes, yet randomized controlled trials (RCTs) evaluating the combined effects of physical, respiratory, occupational, and speech therapy initiated within the first 24–72 hours are lacking. Methods: This single center, controlled clinical trial aims to establish the efficacy and safety of an early multimodal rehabilitation program (MRP) compared with a late MRP in mechanically ventilated patients admitted to the ICU. Adult patients (≥18 years) with a Barthel score ≥70 and requiring invasive mechanical ventilation for more than 24 hours will be included. Participants will be randomly assigned to early MRP, initiated within 24 hours post-intubation, or late MRP, starting 72 hours post-intubation. The primary outcome is the duration of mechanical ventilation. Safety will be assessed by comparing the number of adverse events between groups. The MRP includes passive and active interventions from physical, speech, respiratory, and occupational therapy teams. Therapy intensity and type are adjusted according to the patient’s Richmond Agitation-Sedation Scale (RASS) score. Patients with lower RASS scores (indicating deeper sedation) will receive primarily passive interventions (e.g., passive range-of-motion exercises), while those with higher RASS scores (indicating lighter sedation or alertness) will engage in more active therapies (e.g., active-assisted exercises and functional mobility activities). For patients with RASS ≥2, occupational therapy will focus on behavioral and environmental modulation, employing calming techniques, sensory stimuli, and cognitive tasks, with family education to support spatiotemporal orientation. This adaptive approach ensures patient safety and optimizes therapy based on the patient’s current sedation level and clinical condition. Dissemination: The results will be published in peer-reviewed journals and presented at conferences. Trial registration: ClinicalTrials.gov NCT06133504. Registered on November 11, 2023.

Background: The COVID-19 pandemic has resulted in a critical shortage of respiratory ventilators, highlighting the urgent need to explore alternative treatment options for patients with acute respiratory distress syndrome (ARDS) caused by respiratory viruses, as an alternative to invasive mechanical ventilation (IMV) in future pandemics. Objectives: The objective of this study was to assess the effectiveness of alternative noninvasive oxygenation and ventilation strategies in comparison to invasive mechanical ventilation (IMV) in patients with virus-induced acute respiratory failure (ARF). The primary outcome was the all-cause ICU mortality rate. Methods: A systematic review was conducted following the Cochrane guidelines and PRISMA reporting guidelines. The search encompassed databases such as Medline, Cochrane CENTRAL, and Embase to identify relevant indexed literature. Additionally, gray literature was included by consulting regulatory agencies. The included studies compared various oxygenation and ventilatory alternatives, such as high-flow nasal cannula (HFNC), continuous positive airway pressure (CPAP), or noninvasive mechanical ventilation (NIMV) with IMV. An exploratory meta-analysis was performed by calculating the risk ratio (RR) by random effects and meta-regression to explore possible sources of heterogeneity and to compare ventilatory alternatives against IMV to reduce mortality, length of stay (LOS) days in ICU, nosocomial infection, and barotrauma. Results: A total of forty-seven studies were included in this systematic review. NIMV had an RR of 0.70 (0.58–0.85), HFNC had an RR of 0.54 (0.42–0.71), and CPAP had an RR of 0.80 (0.71–0.90), with meta-regression models that reduced heterogeneity to 0%. For LOS days in ICU, NIMV had 0.38 (− 0.69: − 0.08) lower days and HFNC 0.29 (− 0.64: 0.06) lower days with meta-regression models that reduction heterogeneity to 0% for HFNC and 50% for NIMV. Not enough studies reported nosocomial infection or barotrauma to evaluate them in a meta-analysis. The overall quality of evidence, as assessed by GRADE evaluation, was determined to be from very low to medium certainty depending on the ventilatory strategy and outcome. Conclusions: The findings of this systematic review support the use of alternative noninvasive oxygenation and ventilation strategies as viable alternatives to conventional respiratory ventilation for managing viral-induced ARF. Although it is essential to interpret these findings with caution given the overall low to medium certainty of the evidence, the integration of these modalities as part of the management strategies of these patients could help reduce the utilization of ICU beds, invasive ventilators, and costs in both developed and developing countries.