Nicolò Sella

Background: Early extubation after bilateral lung transplantation (LT) may reduce intensive care unit (ICU) complications, but evidence from heterogeneous real-world cohorts and of its impact on mid-term functional recovery remains limited. Methods: We conducted a single-centre observational study of 149 consecutive adult bilateral LT recipients (February 2016–February 2023). Patients extubated within 24 h were assigned to the early extubation (EE) group (n = 63, 42%) (extubated within 24 h of the end of surgery), while those extubated later comprised the late extubation (LE) group (n = 86, 58%) (extubated beyond 24 h). Multivariable logistic regression identified predictors of late extubation. Outcomes included postoperative extracorporeal membrane oxygenation (ECMO), pneumonia, ICU length of stay, and spirometric parameters at 9–12 months after LT. Results: Higher Lung Allocation Score (LAS; adjusted OR 1.19, 95% CI 1.02–1.38) and intraoperative red blood cell (RBC) transfusions (adjusted OR 1.47, 95% CI 1.04–2.06) independently predicted late extubation. Compared with the LE group, EE recipients required less postoperative ECMO (2% vs. 23%; p = 0.008), had shorter inhaled nitric oxide treatment (7 vs. 17 h; p = 0.006), lower pneumonia rates (8% vs. 23%; p = 0.043), and shorter ICU stays (6 vs. 9 days; p = 0.005). In-hospital and 1-year mortality were similar between groups. At 9 ± 1 months, EE recipients showed better volumetric lung recovery, with higher FVC as a percentage of pre-transplant baseline (78.0% vs. 69.5%; p = 0.048) and higher TLC percentage predicted (77% vs. 68%; p = 0.015). Airflow indices and respiratory muscle strength did not differ. Conclusions: In a broadly inclusive LT cohort, higher LAS and intraoperative RBC transfusion independently predicted late extubation. Early extubation was associated with lower postoperative support requirements and was associated with higher FVC relative to pretransplant baseline, an association that should be interpreted in light of the unadjusted comparison and baseline heterogeneity rather than as evidence of a causal benefit.

Background: Critically ill patients generate large volumes of complex data, creating challenges for timely clinical decision making in intensive care units (ICUs). Artificial intelligence (AI) has emerged as a promising tool for supporting diagnosis, monitoring, prognostication, and workflow optimization in this setting. This scoping review aimed to map current AI applications in critical care and identify practical clinical applications.Methods: A systematic search of the MEDLINE, Scopus, and EMBASE databases was conducted for studies published between January 2015 and June 2025. Eligible studies evaluated practical AI applications in ICU settings involving patients, relatives, or healthcare professionals. Data pertaining to study design, AI techniques, clinical domains, outcomes, model characteristics, and implementation features were extracted. Results: In total, 112 studies were included. Most were retrospective observational studies (59.8%) focusing on adult populations. Machine learning was the predominant technology used (76.8%), and the main clinical applications were outcome and mortality predictions, early warning systems, and monitoring, particularly in neurological and respiratory domains. Notably, 24.1% of included studies relied on North American public databases, raising concerns about geographic data monoculture, and only 27.7% of the systems provided real-time bedside applications. Most systems remained at the experimental stage, with limited real-world implementation, heterogeneous performance reporting, and a frequent lack of external validation.Conclusions: AI applications in ICUs have expanded rapidly and show substantial promise for improving patient care and workflow efficiency. Future research should prioritize prospective multicenter validation, explainability, and implementation science to ensure the safe and effective integration of AI into critical care.

Purpose: The benefits of adopting restrictive transfusion strategies, as opposed to a liberal approach, during extracorporeal membrane oxygenation (ECMO) remain unclear. This network meta‐analysis aims to determine whether a restrictive transfusion strategy is more effective than liberal thresholds in minimizing red blood cell (RBC) transfusions and improving secondary outcomes. Methods: A comprehensive literature search (PROSPERO‐CRD42025637794) across Medline, Embase, and Scopus was conducted. All studies enrolling adults on ECMO, receiving RBC transfusions according to either restrictive or 'targeted' thresholds, compared to liberal thresholds, were included. The primary outcome was the number of RBC transfusions during ECMO. Secondary outcomes included the use of fresh frozen plasma (FFP) and platelet units, ECMO duration, and survival. Results: Five retrospective observational studies (1339 patients) met the inclusion criteria. RBC transfusions were lower when a transfusion threshold of 7 g/dL was used, compared to a liberal threshold (mean difference (MD) −5.75, 95% confidence interval (CI) −10.90 to −0.59, p = 0.029), while not with thresholds of 8 or 9 g/dL. Both FFP and platelet transfusions were reduced at thresholds of 7 g/dL and 9 g/dL, compared to liberal transfusion strategies. A shorter ECMO duration was observed only at a threshold of 9 g/dL (MD −1.06, 95% CI −2.11 to −0.01, p = 0.048). Finally, a restrictive threshold of 7 g/dL improved 28‐day survival. Conclusions: A restrictive transfusion strategy reduces the number of blood products administered to ECMO patients and, secondarily, ECMO duration and mortality at 28 days. However, our findings may not be generalizable to patients with severe thrombocytopenia, bleeding disorders, or underlying cardiac conditions who may be potentially benefiting from higher transfusion thresholds.

Background: Veno-venous extracorporeal membrane oxygenation (V-V ECMO) represents a progressively adopted life-sustaining intervention worldwide, particularly in the management of acute respiratory distress syndrome. Nevertheless, data concerning the prognostic significance of fungal isolation in this setting remain unclear. This study aims (i) to assess the incidence of fungal infection and colonization in a homogeneous cohort of V-V ECMO patients, and (ii) to evaluate the association between fungal infection or colonization and 1-year mortality, with a focus on the impact of specific fungal species. Methods: All consecutive adults admitted to the Intensive Care Units of five Italian university-affiliated hospitals and requiring V-V ECMO were screened. Exclusion criteria were age < 18 years, pregnancy, veno-arterial or mixed ECMO-configuration, incomplete records and survival < 24 h after V-V ECMO placement. A standard protocol of microbiological surveillance was applied and the distinction between different fungal species were made through in vivo and vitro tests. Cox-proportional hazards models, Kaplan–Meier curves and linear logistic regressions were applied for investigating mortality. Results: Two-hundred and seventy-nine V-V ECMO patients (72% male) were enrolled. The overall fungal isolation was 41% (n. 114): 23% infections and 18% colonizations. The overall 1-year mortality, among fungal isolations, was 40%, with no different risk in case of fungal infection (26 out of 63, 41%) (aHR 0.85, 95% CI [0.53–1.37], p-value 0.505) and colonization (20 out of 51, 39%) (aHR 0.86, 95%CI [0.51–1.43], p-value 0.556), as compared to patients never detecting fungi (68 out of 165, 41%, reference). According to the isolated mycotic species, as compared to Candida sp. group (reference), the risk of death was greater when different fungal species (e.g., Aspergillus sp. and Candida sp.) were concomitantly isolated in the same patient (OR 1.17, 95%CI [1.12–11.07], p-value 0.031. Conclusions: In the overall population, 23% V-V ECMO patients recorded ‘late’ fungal infections and 18% fungal colonizations, with a similar risk of death as compared to patients never experiencing fungi during the V-V ECMO course. The detection of concomitant different fungal species was an independent risk factor for 1-year mortality.

Background/Objectives: Managing ventilatory strategies in patients with obesity under general anesthesia presents significant challenges due to obesity-related pathophysiological changes. Inverse ratio ventilation (IRV) has emerged as a potential strategy to optimize respiratory mechanics during laparoscopic surgery in this population. The primary outcomes were changes in respiratory mechanics, including peak inspiratory pressure (P_Peak), plateau pressure (P_Plat), mean airway pressure (P_Mean), and dynamic compliance (C_Dyn). Secondary outcomes included gas exchange parameters, hemodynamic measures, inflammatory cytokines, and postoperative complications. Methods: A systematic review and meta-analysis were conducted, searching PubMed, Scopus, EMBASE, and PMC Central. Only English-language randomized controlled trials (RCTs) evaluating the impact of IRV in adult surgical patients with obesity were included. The quality and certainty of evidence were assessed using the Risk of Bias 2 (RoB 2) tool and the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) framework, respectively. Results: Three RCTs including 172 patients met the inclusion criteria. Compared to conventional ventilation without prolonged inspiratory time or IRV, IRV significantly reduced P_Peak (MD [95%CI]: −3.15 [−3.88; −2.42] cmH₂O, p < 0.001) and P_Plat (MD [95%CI]: −3.13 [−3.80; −2.47] cmH₂O, p < 0.001) while increasing P_Mean (MD [95%CI]: 4.17 [3.11; 5.24] cmH₂O, p < 0.001) and C_Dyn (MD [95%CI]: 2.64 [0.95; 4.22] mL/cmH₂O, p = 0.002) during laparoscopy, without significantly affecting gas exchange. IRV significantly reduced mean arterial pressure (MD [95%CI]: −2.93 [−3.95; −1.91] mmHg, p < 0.001) and TNF-α levels (MD [95%CI]: −9.65 [−17.89; −1.40] pg/mL, p = 0.021). Conclusions: IRV optimizes intraoperative respiratory mechanics but has no significant impact on postoperative outcomes, necessitating further research to determine its clinical role.

Ischemic stroke, caused by the interruption of the blood supply to the brain, requires prompt medical intervention to prevent irreversible damage. Anesthetic management is pivotal during surgical treatments like mechanical thrombectomy, where precise strategies ensure patient safety and procedural success. This narrative review highlights key aspects of anesthetic management in ischemic stroke, focusing on preoperative evaluation, anesthetic choices, and intraoperative care. A rapid yet thorough preoperative assessment is crucial, prioritizing essential diagnostic tests and cardiovascular evaluations to determine patient frailty and potential complications. The decision between general anesthesia (GA) and conscious sedation (CS) remains debated, with GA offering better procedural conditions and CS enabling continuous neurological assessment. The selection of anesthetic agents—such as propofol, sevoflurane, midazolam, fentanyl, remifentanil, and dexmedetomidine—depends on local protocols and expertise balancing neuroprotection, hemodynamic stability, and rapid postoperative recovery. Effective blood pressure management, tailored airway strategies, and vigilant postoperative monitoring are essential to optimize outcomes. This review underscores the importance of coordinated care, incorporating multimodal monitoring and maintaining neuroprotection throughout the perioperative period.

Background: Infections are one of the most common causes of death after lung transplant (LT). However, the benefit of ‘targeted’ prophylaxis in LT recipients pre-colonized by Gram-negative (GN) bacteria is still unclear. Methods: All consecutive bilateral LT recipients admitted to the Intensive Care Unit of the University Hospital of Padua (February 2016–2023) were retrospectively screened. Only patients with pre-existing GN bacterial isolations were enrolled and analyzed according to the antimicrobial surgical prophylaxis (‘standard’ vs. ‘targeted’ on the preoperative bacterial isolation). Results: One hundred eighty-one LT recipients were screened, 46 enrolled. Twenty-two (48%) recipients were exposed to ‘targeted’ prophylaxis, while 24 (52%) to ‘standard’ prophylaxis. Overall prevalence of postoperative multi-drug resistant (MDR) GN bacteria isolation was 65%, with no differences between the two surgical prophylaxis (p = 0.364). Eleven (79%) patients treated with ‘standard’ prophylaxis and twelve (75%) with ‘targeted’ therapy reconfirmed the preoperative GN pathogen (p = 0.999). The prevalence of postoperative infections due to MDR GN bacteria was 50%. Of these recipients, 4 belonged to the ‘standard’ and 11 to the ‘targeted’ prophylaxis (p = 0.027). Conclusions: The administration of a ‘targeted’ prophylaxis in LT pre-colonized recipients seemed not to prevent the occurrence of postoperative MDR GN infections.