45th International Symposium on Intensive Care & Emergency Medicine.

P001 Physiological effects of high flow nasal cannula oxygen therapy combined with continuous negative extrathoracic pressure in healthy volunteers: a pilot study

SM Colombo 1 , M Leali 2 , L Vivona 3 , F Casano 2 , G Baldin De Bernard 4 , P Bottausci 4 , V Scaravilli 4 , T Mauri 4 , A Zanella 4 , G Grasselli 4

1 Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico, Department of Anesthesia, Critical Care and Emergency, Milan, Italy, 2 Universita degli studi di Milano, Dipartimento di Fisiopatologia MedicoChirurgica e dei Trapianti, Milan, Italy, 3 IRCCS MultiMedica San Giuseppe Hospital, Dipartimento di Anestesia e Rianimazione, Milan, Italy, 4 Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico, Milan, Italy

Critical Care 2026, 30 (Suppl 1): P001

Introduction: High flow nasal cannula (HFNC) and continuous negative extrathoracic pressure (CNEP) are non-invasive respiratory supports that can modulate lung volumes, work of breathing and cardiopulmonary interactions through distinct but potentially complementary mechanisms [1,2]. The combined use of HFNC and CNEP has not yet been systematically evaluated in humans, and its physiological impact on ventilation distribution and intrathoracic pressures remains unclear.

Methods: A single-centre, stepwise physiological study was conducted in healthy volunteers. Participants underwent six sequential 20-min conditions, consisting of spontaneous breathing with and without HFNC at 60 L/min (FiO 2 0.21), each combined with three levels of CNEP (0, -20, -40 cmH 2 O) applied through a thoraco-abdominal cuirass, while continuous monitoring included clinical variables, esophageal and gastric pressures, and electrical impedance tomography (EIT).

Results: 8 subjects have been enrolled (male 75%, age 30.0 ± 5.3 y, BMI 22.8 ± 3.4). Across study phases, respiratory rate, oesophageal pressure swings, and pressure–time product did not show significant changes (Figure), thus no measurable reduction in inspiratory effort. In contrast, CNEP, particularly when combined with HFNC, produced a consistent decrease in end-expiratory gastric pressure while marked increase in end-expiratory lung impedance, likely related to higher end-expiratory lung volume with predominant ventral aeration and a redistribution of tidal ventilation towards dorsal lung regions. Hemodynamic parameters and oxygen saturation remained within normal ranges, and comfort scores decreased at higher negative pressures but were overall acceptable.

Conclusions: Combination of HFNC and CNEP is feasible and in healthy volunteers is associated with increased end-expiratory lung volume, ventral aeration and dorsal redistribution of ventilation, without detectable changes in inspiratory effort.

References Tonelli R et al. Crit Care 2025;29:339 Rochwerg B et al. Intensive Care Med 2019;45:563–572

Figure (abstract P001) Results. RR: respiratory rate; ΔPes: esophageal pressure swing; Pga_ee: end-expiratory gastric pressure; PTPtd: pressure-timp0e-product transdiaphragmatic pressure; CNEP: continuous negative extrathoracic pressure in the cuirass; ΔEELI: variation in end expiratory lung impedance; ΔZ: tidal breath impedance variation. *) p < 0.05 vs. SB, #) p < 0.05 vs. SB CNEP LOW, &) p < 0.05 vs. SB CNEP HIGH, $) p < 0.05 vs. HFNC, @) p < 0.05 vs. HFNC CNEP LOW

P002 Home bronchoscopy: a real improvement for tracheostomized and tracheoventilated patients

E Colombaroli, C Malandruccolo, M Carlini, F Righetti

UTI San Bonifacio AULSS9 Scaligera, Anesthesiology and Reanimation, San Bonifacio Verona, Italy

Critical Care 2026, 30 (Suppl 1): P002

Introduction: Tracheostomized and tracheoventilated patients who live at home are very fragile, difficult to move to hospital with discomfort and transport-related risks. We performed home bronchoscopy, to simplify their care, analysing the risk and the benefit, to reduce hospital admissions and clinical risk of infection.

Methods: We performed home bronchoscopy to tracheostomized and tracheoventilated adult patients once a year under local anesthesia with lidocaine 4% with MAD (Mucosal Atomization Device), using oximeter and frequency measurement as monitoring and disposable bronchoscopy Ambu aScope4 ® for the procedures. We performed bronchoscopy through the cannula. In case of anticoagulated patient, it is interrupted few days before in order to avoid bleeding. The evaluation aims to diagnose any type of tracheal lesion related to aspiration, decubitus of the tracheostomy tube or cuff and tracheomalacia, to improve home management by their care-givers.

Results: We performed 258 home bronchoscopy. The procedure was tolerated by everyone without adverse events, as bleeding or desaturation. The patients maintained ventilation or oxygen supplementation if they habitually use them. The bronchoscopy showed 37 patients (14%) with minimal tracheal lesion and decubitus of the tracheostomy tube or cuff and 22 patients (8%) with tracheomalacia; in all of them we recommended reducing the tracheobronchial aspirations in order to avoid mucosal lesions and the correct measurement of cuff pressure. In 6 patients (2%) a granuloma was visualized, with endoscopy indication for removal.

Conclusions: Home bronchoscopy is a safe and well tolerated procedure; it can reduce the discomfort of moving the patients, reducing transportation costs and risks. It helps to manage most patients directly, improving care giver education.

P003 Evaluating the trend of the ROX index to predict failure of nasal high-flow oxygenation

V Lertritdecha, W Thongtaeparak

Phramongkutklao Hospital, Division of Pulmonary and Critical Care Medicine, Bangkok, Thailand

Critical Care 2026, 30 (Suppl 1): P003

Introduction: High-flow nasal cannula (HFNC) is recommended for patients who have been extubated in high-risk groups. Patients who did not show clinical improvement in 48 h of utilizing HFNC and the attending physician delayed reintubation; the outcome deteriorated, and the mortality rate increased.

Methods: This prospective observational cohort study was conducted between July 2024 and December 2024. The study included patients admitted to the medical intensive care unit (ICU) at Phramongkutklao Hospital with respiratory failure. Following extubation, all patients were initiated on HFNC and ROX index was monitored. The primary outcome was the diagnostic accuracy of cut-off value for ROX index change to predict HFNC failure. Secondary objectives were to evaluate the ROX index change to predict 24 h and factors associated with HFNC failure.

Results : From a total of 70 patients who received HFNC after extubation, 58 patients were in the HFNC success group, and 12 patients were in the HFNC failure group. Receiver operating characteristic (ROC) curve analysis was performed to diagnostic accuracy of cutoff value of ROX index change to predict HFNC failure. ROX index change at 24 h reduced by 0.55 can predict HFNC failure, resulting in sensitivity of 75.0%, specificity of 89.8% and area under the ROC 0.838 (Figure). At 24 h, with the HFNC failure group showing a negative trend compared to the HFNC success group (-1.00 ± 2.64 vs. 2.91 ± 3.73, p = 0.001).

Conclusions: The ROX index change at 24 h reduced by 0.55 can predict HFNC failure and diagnostic accuracy represented by an area under the ROC curve of 0.838. The ROX index change at 24 h shows a statistically significant change between the success and failure groups.

Figure (abstract P003) ROC curve for cutoff value for ROX index change to predict HFNC failure at 24 h

P004 Dynamic assessment of ROX index trajectories predicts high-flow oxygen therapy failure in acute hypoxemic respiratory failure

CJ Chang 1 , CN Tai 2 , MS Hung 2 , CM Lin 2 , CH Hung. 3

1 Chiayi Chang Gung Memorial Hospital, Department of Respiratory Therapy, Puzi City, Chiayi County, Taiwan, Republic of China, 2 Chiayi Chang Gung Memorial Hospital, Department of Pulmonary and Critical Care Medicine, Puzi City, Chiayi County, Taiwan, Republic of China, 3 National Cheng Kung University, Institute of Allied Health Sciences, College of Medicine, Tainan, Taiwan, Republic of China.

Critical Care 2026, 30 (Suppl 1): P004

Introduction: This study aimed to determine whether both the absolute level and the temporal rate of change (slope) of the respiratory rate-oxygenation (ROX) index are dynamically associated with the risk of high-flow oxygen therapy (HFOT) failure in adults with acute hypoxemic respiratory failure (AHRF). The ROX index was defined as (SpO₂/FiO₂) divided by the respiratory rate.

Methods: We conducted a retrospective single-center study including adults with AHRF receiving HFOT between January and December 2024. Serial ROX values were recorded at 0, 2, 6, 12, and 24 h. A joint longitudinal-survival model simultaneously described individual ROX trajectories using a linear mixed-effects model and the time to HFOT failure (intubation, transition to noninvasive ventilation, or death) using a Weibull relative-risk model. Both the predicted ROX value and its temporal derivative (slope) were modeled as time-dependent covariates. Integration was performed using adaptive Gauss-Hermite quadrature (five points).

Results: A total of 1793 ROX measurements were analyzed (414 subjects; 226 failures, 54.6%). In the value + slope joint model, higher ROX values were associated with lower failure risk (association coefficient, Assoct = -0.3548; hazard ratio [HR] = 0.70; p < 0.001), whereas faster ROX increase independently indicated higher risk (Assoct.s = + 0.3646; HR = 1.44; p < 0.001) (Table). The Weibull shape parameter (0.63; log[shape] = -0.4624) indicated a decreasing baseline hazard over time, and the model demonstrated a good fit and stable convergence (AIC = 12,241.9). These findings suggest that the prognostic meaning of ROX depends not only on its level but also on its short-term evolution.

Conclusions: Both the instantaneous ROX value and its slope independently predict HFOT failure. While higher ROX levels are protective, a rapid rise may reflect compensatory effort and impending deterioration. Incorporating ROX dynamics into real-time monitoring may improve early identification of patients at risk for HFOT failure.

Table (abstract P004) Association between ROX dynamics and HFOT failure (joint model)

P005 Pre-hospital respiratory rescue: a new breakthrough device

G Landoni 1 , K Donadello 2 , L Cabrini 3 , G Giardina 4 , E Salurso 5 , F Ciceri Negri 5 , GB Fiore 5 , A Redaelli 5 , F Consolo 6

1 VitaSalute San Raffaele University, Dept of Anesthesia ICU, Milan, Italy, 2 AOUI University Hospital Integrated Trust of Verona, Anaesthesia and Intensive Care B Unit, Verona, Italy, 3 Ospedale di Circolo, ASST Setta Laghi, Unit of General and Neurosurgical Intensive Care, Varese, Italy, 4 IRCCS San Raffaele Scientific Institute, Department of Anesthesia and Intensive Care, Milan, Italy, 5 Politecnico Di Milano, Department of Electronics, Information and Bioengineering, Milan, Italy, 6 VitaSalute San Raffaele University, Department of Electronics, Information and Bioengineering, Milan, Italy.

Critical Care 2026, 30 (Suppl 1): P005

Introduction: Acute respiratory failure is a medical emergency that can rapidly become fatal. We developed and preclinically validated a portable CPAP device specifically designed for emergency out-of-hospital use which is intuitive and easy to use, enabling even individuals without specific technical skills or expertise to intervene promptly.

Methods: We designed and developed a new highly compact CPAP system allowing one-handed operation and ensuring ergonomic usability (Figure). We evaluated the device prototype performance using a high-fidelity lung simulator to test the ability to maintain a target pressure of 5 cmH₂O under varying respiratory conditions. 15 volunteers with different levels of experience with respiratory support devices and emergency care tested it.

Results: Under all the pathological simulated scenarios (COPD, asthma, ARDS) the prototype device consistently stabilized PEEP at the target 5cmH2O value. 93% of operators confirmed that the device was intuitive and easy to apply.

Conclusions: The device delivered a PEEP which was stable at ~ 5 cmH₂O. Operators reported that the device is straightforward to use and requires no prior technical or clinical training. These results indicate strong potential for real-world application as an early respiratory support tool to shorten the time to treatment and improve outcomes for acute respiratory failure patients. A clinical validation study is currently in progress.

Acknowledgements: Funded by the European Union-Next Generation EU-NRRP M6C2-Investment 2.1 Enhancement and strengthening of biomedical research in the NHS. Project ID: PNRR-POC-2022-12376704—CUP Master C43C22001390007. Project title: PREVENT—A new portable device for PRE-hospital non-invasive VENTilatory support in acute respiratory failure.

Figure (abstract P005) The miniaturized CPAP device. (A) front-left view showing (1) air inflow at the top of the enclosure, (2) indentations on the external enclosure for comfortable and secure hold during device application, (3) on/off button, (4) anti-asphyxiation valve, (5) 5 cmH 2 O PEEP valve, (6) nasal-oral mask. (B) front-right side view showing (7) LED indicator of the battery pack charging status. (C) internal view showing (8) particulate filter located on top of the (9) centrifugal fan, (10) airflow distribution chamber located downstream of the fan, (11) 10 comH 2 O PEEP valve, (12) control system board, and (13) lower compartment containing the battery pack. Modified from [1]

Reference Salurso E et al. Signae Vitae. 2026. 10.22514/sv.2025.185

P006 Double trunk mask: a simple open-source device to enhance Fio 2 at low oxygen flow

W Nabhan, A Khaldi, S Mashayekhi, C Hickmann, V Durant, F Duprez

EpiCura, USI, Hornu, Belgium

Critical Care 2026, 30 (Suppl 1): P006

Introduction: The Double Trunk Mask (DTM) consists of a standard aerosol mask into which two corrugated tubes are inserted through its lateral openings [1]. When positioned over a conventional oxygen nasal cannula (NC), these tubes act as oxygen reservoirs during expiration, thereby increasing the volume of oxygen available for the subsequent inspiratory phase and enhancing the FiO₂ [2]. The aim of this bench study was to assess the FiO₂ delivered with the DTM + NC compared with the NC alone.

Methods: The FiO₂ delivered by a DTM combined with a nasal cannula (DTM + NC) was compared with that of the NC alone using an adult lung model driven by a mechanical ventilator. The resistive and elastic characteristics of the test lung were set to 5 cmH₂O/L/s and 0.06 L/cmH₂O, respectively. Data acquisition was performed using LabScribe 3™ software (iWorx®), after a stabilization period. Experimental parameters were adjusted as follows: O₂ flow 1–6 L/min, tidal volume 0.5 L, respiratory rate 10–30 cycles/min, and Ti/Ttot ratio 0.33.

Results: The DTM dramatically increases FiO₂ compared with oxygen delivery via NC alone. Linear regression analyses showed a strong correlation between O₂ flow rate and FiO₂. Regressions of ΔFiO₂ confirmed a significant DTM-related increase, particularly at lower flow rates (Figure).

Conclusions: The DTM + NC significantly increases FiO₂ compared with NC alone. The DTM has been used for several years in our hospital, particularly during the COVID-19 pandemic, with its safety, tolerance, and lack of PaCO₂ increase already well documented. These results reinforce the DTM’s physiological effectiveness and support its role as a simple, safe, and efficient complement to conventional oxygen therapy.

Figure (abstract P006) Linear regressions for measured FiO 2 with and without Double Trunk Mask (Vt = 500 mL), up to 6 L/min

References Duprez F et al. Respir Care 2019; 64:908–914 Duprez F et al. Lancet Glob Health. 2025; 13:e992-e993

P007 Preventive measures for dental injury associated with supraglottic airway use: a scoping review

M Akatsuka 1 , Y Nakamura 2

1 Sapporo Medical University School of Medicine, Department of Biochemistry, Sapporo, Japan, 2 Sapporo Medical University Hospital, Division of Clinical Engineering, Sapporo, Japan

Critical Care 2026, 30 (Suppl 1): P007

Introduction: Perioperative dental injury (PDI) remains a significant cause of morbidity. While supraglottic airway (SGA) devices are generally considered less traumatic than endotracheal intubation, specific risks such as insertion trauma and biting during emergence remain clinically relevant. This scoping review aimed to map existing evidence on preventive measures for dental and oral injury specifically associated with SGA use in adult patients.

Methods: This scoping review followed JBI methodology. Electronic databases were searched for randomized controlled trials and observational studies reporting preventive interventions for dental/oral trauma during SGA use. Data on device types, prevention strategies, and injury outcomes were extracted.

Results: Twenty-eight included studies identified preventive measures across five domains: physical protection, insertion technique, device selection, emergence management, and systemic intervention. Regarding physical protection, soft bite blocks significantly reduced mucosal bleeding (0% vs 13%, p < 0.01) compared to rigid airways [1]. For insertion techniques, guided methods using a bougie [2] demonstrated less trauma than blind insertion. In terms of device selection, second-generation SGAs showed more favorable safety profiles than first-generation devices. Pharmacological management using remifentanil infusion significantly improved smooth removal ( p = 0.002) [3]. Finally, systemic intervention via standardized preoperative assessment reduced injury incidence from 0.108% to 0.009% [4].

Conclusions: Preventing dental injury during SGA use requires a multimodal approach. Evidence supports guided insertion techniques, avoidance of rigid bite blocks, pharmacological management of emergence, and systemic risk assessment.

References Keller C et al. Acta Anaesthesiol Scand 1997;41:1171–1174 Tosh P et al. Anesth Essays Res 2021;15:183–187 Özkan D et al. J Anesth 2012;26:369–374 Kuo YW et al. J Chin Med Assoc 2016;79:678–682

P011 Preventing aspiration events in hospital using prophylactic antiemetics: a systematic review and meta-analysis

K.B Tworek 1 , M Giovannoni 1 , J Kung 2 , V Lau 3

1 University of Alberta, Department of Medicine, Edmonton, Canada, 2 University of Alberta, Geoffrey Robyn Sperber Health Sciences Library, Edmonton, Canada, 3 University of Alberta, Department of Critical Care Medicine, Edmonton, Canada

Critical Care 2026, 30 (Suppl 1): P011

Introduction: Aspiration events in hospitalized adults are common and linked to substantial morbidity and mortality. While antiemetics have been studied for aspiration prevention in specific settings, evidence for their broader preventive use in hospitalized adults is limited. We conducted a systematic review and meta-analysis to evaluate the effect of prophylactic antiemetics on aspiration events in adult inpatients.

Methods: Ovid MEDLINE, Ovid Embase, CINAHL, and Cochrane Library (via Wiley) were searched in May 2025. Results were reviewed independently by two investigators to identify eligible studies. We included randomized controlled trials (RCTs) and observational studies assessing antiemetic use in hospitalized adults, with aspiration events as the primary outcome. Secondary outcomes were pneumonia, hospital length of stay, and mortality.

Results: Three RCTs met inclusion criteria (n = 515; 237 antiemetic, 278 placebo), only two RCTs reported on aspiration events (n = 210; 106 antiemetic, 104 placebo). Pooled analysis demonstrated an 88% relative risk [RR] reduction of aspiration events in those receiving prophylactic antiemetics (3/106 (2.8%) antiemetic vs 29/104 (27.9%) placebo; mean difference 25.1%, RR = 0.12, 95% confidence intervals [CI]: 0.02–0.73, p < 0.0001) (Figure). Although the reduction in pneumonia did not reach statistical significance, the antiemetic group showed a favorable trend compared with placebo (39/237 (16.5%) antiemetic, 90/278 (32.4%) placebo; mean difference 15.9%, RR = 0.44, 95% CI: 0.15–1.28, p = 0.15). Mortality rates were comparable between groups (83/237 (35.0%) antiemetic, 106/278 (38.1%) placebo; mean difference 3.1%, RR = 1.02, 95% CI: 0.84–1.24, p = 0.85).

Conclusions: Prophylactic antiemetics were associated with a significant reduction in aspiration events and a non-significant but favorable trend towards reduction of pneumonia among hospitalized adults. Larger, high-quality RCTs are needed to clarify their role in aspiration prevention.

Figure (abstract P011) Forest plots of pooled analysis of incidence of A) aspiration events and B) pneumonia among included studies

P012 The modified Evan’s blue dye test has high positive predictive value for diagnosing aspiration in tracheostomized critically ill patients: a systematic review and meta-analysis

E Szoke 1 , C Turan 2

1 Semmelweis University, Centre for Translational Medicine, Budapest, Hungary, 2 Semmelweis University, Intensive Care Unit, Budapest, Hungary

Critical Care 2026, 30 (Suppl 1): P012

Introduction: Dysphagia and aspiration are common complications in tracheostomized critically ill patients. The Modified Evan’s Blue Dye Test (MEBDT) is a non-invasive, easy-to-perform dysphagia screening tool, but its accuracy compared to the gold standard Fiberoptic Endoscopic Evaluation of Swallowing (FEES) in these patients remains unclear.

Methods: Study protocol was prospectively registered on PROSPERO (CRD: 42023479920). A systematic search was conducted across three databases (PubMed, Cochrane Central, and Embase), followed by a systematic screening against predetermined selection criteria. The included studies reported the sensitivity and specificity of MEBDT versus FEES. The risk of bias and the level of evidence certainty in the included papers were assessed by the QUADAS-2 tool and GRADE approach respectively.

Results: Six out of 2227 screened studies were included. We found that MEBDT had a high specificity 95.42% (95% CI [67.38%, 99.53%]) and positive predictive value 95% (95% CI [81, 100]) (Figure).

Conclusions: In conclusion, MEBDT is a reliable tool for assessing aspiration in tracheostomized patients, especially when positive. Nonetheless, a negative MEBDT still requires further investigations with FEES to confirm the absence of dysphagia and aspiration.

Figure (abstract P012) Random-effects bivariate diagnostic meta-analysis of negative predictive value and positive predictive value of the Modified Evan’s Blue Dye Test compared to the Fiberoscopic Evaluation of Swallowing in the diagnosis of aspiration

P013 Impairment of deglutition in tracheostomized critical care patients

E Sertaridou 1 , P Bempeletsi 2 , M Nakou 1 , K Nikolaou 1 , C Alexopoulou 1 , V Papaioannou 1

1 University Hospital of Alexandroupolis, Intensive Care Unit, Alexandroupolis, Greece, 2 University Hospital of Alexandroupolis, Physiotherapy and Rehabilitation Department, Alexandroupolis, Greece

Critical Care 2026, 30 (Suppl 1): P013

Introduction: Invasive airway access for assisted ventilation has been implicated in swallowing impairment. This study aims to evaluate the deglutition function in tracheostomized ICU patients.

Methods: This prospective study has been included adult ICU patients who underwent percutaneous tracheostomy. Exclusion criteria were altered state of consciousness (GCS < 11) due to disease or sedative/analgesic treatment, mental dysfunction (RASS score < -2 or > + 2 and/or possitive CAM-ICU) and any underlying disease or trauma precluding assessment of the neuromuscular function. After cuff deflation, enrolled patients were clinically evaluated for laryngeal elevation, hypopharyngeal and laryngeal sensation, vocal cord function and cough reflex. Dysphagia was recognized with Gugging Swallowing Screen (GUSS) and the blue dye test, while selected subjects underwent Flexible Endoscopic Evaluation of Swallowing (FEES). Moreover, ICU myopathy was assessed using the Medical Research Council (MRC) Scale for Muscle Strength.

Results: Among 350 patients admitted to the ICU in 10-month period, 88 were tracheostomized, among who 28 were eligible for the study. The tracheostomy was performed after median 9 days since ICU admission (range 4–20 days) and dysphagia was assessed in median 11 days (range 5–33 days). The median GCS score at evaluation time was 15/15 (range: 11–15/15) and RASS score 0 (range: -1 to + 1). The patients presented significant myopathy (median MRC score: 36/60, range: 12–48/60) and notable swallowing disorders (median GUSS score: 7/10, range: 3–10/10). Of note, 12/28 patients (39.3%) with GUSS score < 7/10 were assessed by FEES, which revealed a high risk of aspiration. There was no significant correlation between MRC and GUSS score (Spearman’s r 0.12, p 0.6).

Conclusions: This study demonstrated a noteworthy prevalence of post-tracheostomy dysphagia and a high risk of aspiration. Thus, systematic evaluation of deglutition could allow early identification of the disorder and appropriate treatment modifications.

P015 Pleurodesis with fresh frozen plasma (FFP) for recurrent pneumothorax in patients with pulmonary contusions

K Tsikritsaki, S Antonopoulou, A Mantzioros, R Koliogeorgi, A Vilaeti, E Triantafillidou, M Anyfanti, V Zarkada, A Kalogeromitros, G Koukoulitsios

General Hospital of Athens G. Gennimatas, ICU, Athens, Greece

Critical Care 2026, 30 (Suppl 1): P015

Introduction: Intrapleural instillation of fresh frozen plasma (FFP) is a minimally invasive alternative for managing postoperative air leaks, potentially avoiding the adverse effects of chemical pleurodesis. This study evaluated the efficacy and safety of FFP pleurodesis in patients with recurrent pneumothorax due to pulmonary contusions.

Methods: From January 2018 to September 2025, 12 patients with recurrent pneumothorax secondary to pulmonary contusions underwent FFP pleurodesis. Two chest tubes were placed, one basally and one apically. One unit of ABO-compatible FFP was instilled through the basal tube, which was then sealed and elevated approximately 60 cm to retain the plasma within the pleural space for 24 h, while the apical tube maintained air evacuation. Tubes were removed sequentially following cessation of air leak and radiographic lung re-expansion.

Results: Of the 12 patients treated, 10 (83%) achieved successful outcomes. One patient required a subsequent procedure, while another underwent surgical decortication for an unresolved air leak. No complications or adverse events were noted.

Conclusions: Intrapleural FFP instillation is a safe, effective, and technically simple option for recurrent pneumothorax associated with pulmonary contusions. The absence of complications suggests it may serve as a promising alternative to chemical pleurodesis. Larger studies are needed to further define its role and optimal indications.

P016 Non-aerated lung is proportional to the transpulmonary pressure when positive pressures are reduced in patients weaning from mechanical ventilation

H Widing 1 , M Gudmundsson 1 , C Rylander 2 , G Perchiazzi 2 , P Persson 1

1 University of Gothenburg, The Institute of Clinical Sciences, Gothenburg, Sweden, 2 Uppsala University, Department of Surgical Sciences, Uppsala, Sweden

Critical Care 2026, 30 (Suppl 1): P016

Introduction: The extent of atelectasis formation in response to the gradual reduction of positive pressures during assisted spontaneous breathing is unknown. Whether the formation of atelectasis is proportional to the end-expiratory transpulmonary pressure (PLEE) and whether the PLEE may be used to guide the weaning process has not been explored in clinical settings. We aimed to test the correlation between the volume of atelectasis and the PLEE in patients being weaned from mechanical ventilation in an intensive care unit.

Methods: Ten mechanically ventilated patients were included in the study. All patients were ventilated using pressure support ventilation with positive end-expiratory pressure (PEEP). Repeated computed tomography scans and measurements of esophageal pressure by high-resolution manometry were acquired during a gradual reduction of PEEP and level of pressure support. The volume of atelectasis was calculated and correlated to the PLEE using linear mixed models for repeated measures.

Results: The median (IQR) amount of end-expiratory atelectasis increased significantly with reduced ventilator support from 6.79 (4.12) ml to 8.51 (4.48) ml ( p < 0.01). The volume of atelectasis was linearly correlated to the end-expiratory transpulmonary pressure ( p < 0.05) (Figure).

Conclusions: The atelectasis was linearly correlated to the transpulmonary pressure at end-expiration and no transpulmonary pressure threshold was observed for the accelerated formation of atelectasis. Our findings indicate that esophageal and transpulmonary pressure monitoring may contribute to the individualization of the weaning process.

Figure (abstract P016) The volume of atelectasis in correlation to the transpulmonary pressure at end-expiration, with linear mixed effects model presented

P017 Retrospective cohort study of flow index trajectories: application of explainable machine learning models to predict extubation failure in mechanically ventilated ICU patients

J Shen 1 , S Yang 2 , J Liu 3 , C Liu 2 , X Fu 2 , M Xu 1 , F Yan 2 , X Huang 2 , Y Li 3 , C Pan 2

1 School of Clinical Medicine, Qinghai University, Xining, China, 2 Department of Intensive Care Medicine, Sichuan Academy of Medical Sciences Sichuan Provincial People’s Hospital Affiliated Hospital of University of Electronic Science and Technology of China, Chengdu, China, 3 Office of Medical Information and Data, Medical Support Center, The General Hospital of Western Theater Command, PLA, Chengdu, China

Critical Care 2026, 30 (Suppl 1): P017

Introduction: Among patients who successfully pass a spontaneous breathing trial (SBT), approximately 10%–20% still experience extubation failure, suggesting that conventional SBT indices may not adequately assess respiratory reserve. Monitoring inspiratory effort is a key component in evaluating respiratory reserve, and the Flow index has been shown to noninvasively reflect inspiratory effort.

Methods: This retrospective cohort study first used a latent class trajectory model (LCTM) to classify Flow index patterns, and then applied the least absolute shrinkage and selection operator (LASSO) for feature selection. Five machine learning models were constructed based on the selected variables. Model performance was evaluated in an independent test set, and Shapley additive explanations (SHAP) analysis was performed for the best-performing model.

Results: A total of 432 intensive care unit patients were screened, and 123 were finally included, among whom 27 (21.95%) experienced extubation failure. LCTM identified three trajectories: Traj1, moderately high levels that slowly decreased and stabilized at a moderate level (61.8%); Traj2, moderate levels that continuously declined to a low level (21.95%); and Traj3, moderately high levels that continuously increased to a high level (16.26%). Multivariable logistic regression showed that, compared with Traj2, Traj1 was associated with a significantly lower risk of extubation failure (OR = 0.06, 95% CI 0.01–0.32). The logistic regression model (LRM) had the highest discriminative performance in the test set (AUROC = 0.933, 95% CI 0.852–1.000). SHAP analysis suggested that dynamic lung compliance and Flow index trajectory classification were the most important predictive factors.

Conclusions: An explainable machine learning model constructed using Flow index dynamic trajectories during SBT can, on the basis of conventional weaning indices, significantly improve the identification of patients at high risk of extubation failure.

P018 Dynamic prediction of weaning outcomes in mechanically ventilated patients with acute brain injury

R Zhang, L Liu

Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China

Critical Care 2026, 30 (Suppl 1): P018

Introduction: Weaning from mechanical ventilation remains particularly challenging in patients with acute brain injury (ABI). We aimed to develop a dynamic prediction model capable of providing individualized, time-updated forecasts of weaning outcomes in this population.

Methods: We conducted an observational study using a multicenter prospective cohort and a retrospective cohort from Chinese Database in Intensive Care (CDIC). Intubated adult ABI patients underwent mechanical ventilation for at least 24 h were eligible, while those without a separation attempt were excluded. Data collected included demographics, Sequential Organ Failure Assessment (SOFA), and repeated measurements of Glasgow Coma Scale (GCS) and respiratory parameters during the first 7 days. The primary outcome was weaning failure. The prospective cohort was randomly divided into training (70%) and internal validation (30%) sets; the CDIC cohort was used for external validation. A Bayesian joint model was developed to generate dynamic predictions. Model performance was evaluated using the area under the receiver operating characteristic curve (AUC).

Results: A total of 1585 patients were included (481 prospective, 1104 CDIC), with a median age of 62 [52, 72] years, and 64.6% were males. Intracranial hemorrhage (37.9%) and traumatic brain injury (20.9%) were the most common etiologies. The incidence of weaning failure was 9.8% in the prospective and 7.4% in the CDIC cohort. Age, admission SOFA score, and longitudinal trajectories of GCS motor score, GCS eye score and PaO 2 /FiO 2 were independently associated with weaning failure. The Bayesian joint model demonstrated moderate discrimination in internal validation (overall AUC 0.784; 95% CI: 0.746–0.854), which was corroborated in external validation (overall AUC 0.696; 95% CI: 0.693–0.701) (Figure). The daily AUC showed a gradual improvement over follow-up.

Conclusions: The newly developed model exhibited moderate performance for dynamic prediction of weaning failure in brain injuried patients.

Figure (abstract P018) Discrimination performance of the dynamic prediction model in the (A) internal and (B) external validation.

P019 Effectiveness of a weaning protocol for mechanically ventilated patients in the intensive care unit: a before-and-after study.

A Braz Pereira, G Dias Silva Dutra Macedo, A Caroline Pivovar, R De Geus Koerber, L Alba de Matias, D Delvan, V Hugo Silva Pastorello, A Clara Budal, M Marcela Dadam, G Adrieno Westphal

Hospital Municipal São José, Intensive Care Unit, Joinville SC, Brazil

Critical Care 2026, 30 (Suppl 1): P019

Introduction: The implementation of a structured weaning protocol can reduce extubation failure within 7 days among patients who have undergone more than 72 h of invasive mechanical ventilation (MV).

Methods: This quasi-experimental before-and-after study was conducted in the ICUs of a tertiary hospital in southern Brazil. Phase I involved retrospective collection of baseline data, and Phase II consisted of prospective data collection after implementation of a structured weaning protocol (checklist to assess eligibility for weaning and spontaneous breathing trial (SBT) [1], cough peak flow assessment [2], evaluation and management of post-extubation laryngeal edema risk [3], SBT on T-piece [4], reconnection to MV for one hour after a successful SBT [5], and prophylactic use of noninvasive ventilation in high-risk patients [6]).

Results: A total of 95 patients were included (50 in Phase I and 45 in Phase II). Extubation failure occurred in 17/50 patients (34%) in Phase I and 8/45 (17%) in Phase II (risk difference –17%, 95% CI –0.7 to 33.1; p = 0.06). The hazard of extubation failure was lower in Phase II (HR 0.41, 95% CI 0.15–1.15), consistent with a potential benefit of the protocol (Figure). In multivariable logistic regression, Phase I patients had higher odds of extubation failure compared with Phase II (OR 2.88, 95% CI 1.05–7.87), while each additional risk factor increased failure odds by 22% (OR 1.22, 95% CI 0.99–1.50).

Conclusions: Despite its exploratory design, this study suggests that implementing a structured weaning protocol may reduce extubation failure, independent of baseline risk factors. Larger randomized trials are needed to confirm these results.

Figure (abstract P019) Kaplan–Meier analysis of risk of extubation failure within 7 days after extubation in Phase I vs Phase II groups

References Boles JM et al. Eur Respir J 2007;29:1033–56 Duan J et al. Crit Care 2021;25:357 Fan T et al. BMJ 2008;337:a1841 Thille AW et al. N Engl J Med 2022;387:1843–1854. Fernandez MM et al. Intensive Care Med 2017;43:1660–1667. Boscolo A et al. Eur Respir Rev 2023;32:220196

P020 No intervention safely and reliably reduces the incidence of self-extubation in the ICU: a systematic review and meta-analysis

CT Turan, Z Molnár

Semmelweis University, Department of Anesthesiology and Intensive Therapy, Budapest, Hungary

Critical Care 2026, 30 (Suppl 1): P020

Introduction: Critically ill patients are often intubated and ventilated. Up to 10% of ICU patients self-extubate [1], leading to a potentially life-threatening situation. Despite advancements in overall ICU care, the risk of self-extubation remains high, and this may lead to patients being physically restrained or oversedated, prolonging the duration of mechanical ventilation or potentially causing harm [2]. Our objective was to investigate whether any patient-care measure in the ICU reliably reduced the incidence of self-extubation.

Methods: A systematic search with citation chasing was conducted on PubMed, Embase, and Cochrane CENTRAL on November 16, 2025, with no restrictions. Trial protocols were sought for the corresponding publications. Randomized controlled trials investigating the effects of different interventions against the incidence of self-extubation attempts in ICUs were eligible for analysis. Risk of bias was assessed with RoB2 tool, and the level of evidence certainty was assessed using GRADE. A meta-analysis was conducted using a random-effects model with inverse variance and Paule-Mandel estimation, with subgroups based on interventions. The pre-study protocol was registered on PROSPERO.

Results: 24 trials involving 5,562 mechanically ventilated patients were identified. Trials were further divided into subgroups based on the measure used versus standard care. Overall, no group of measures provides a significant benefit in reducing the incidence of self-extubation (RR: 1.01, 95% CI: 0.78–1.31, τ≈0.03, Q(23) = 24.68, p > 0.05, I2: 6.8%) (Figure). Overall, there are some concerns with risk of bias due to blinding and adherence, and the evidence certainty is very weak due to indirectness and inconsistency.

Conclusions: No intervention in the ICU seems to reliably reduce the incidence of self-extubation. These results underscore the importance of further research in patient management to ensure optimal safety.

Figure (abstract P020) Forest plot depicting the subgrouped and pooled meta-analyses of the incidence of self-extubation

References

Li P et al. Intensive Crit Care Nurs 2022;70:103219 Ely EW et al. JAMA 2004;291:1753–1762

P021 High accuracy of machine learning models in predicting extubation success in mechanically ventilated patients—a systematic review and meta-analysis

P Bakos, B Szabó, D Laczkó, C Turan, S Galin, P Hegyi, L Zubek, A Lovas, Z Molnár

Semmelweis University, Centre for Translational Medicine, Budapest, Hungary

Critical Care 2026, 30 (Suppl 1): P021

Introduction: Optimal timing of extubation in mechanically ventilated patients remains a challenge in intensive care. Machine learning (ML) models show promise in outcome prediction, but their predictive performance in extubation success is still unclear. The aim of this study was to systematically review and quantitatively evaluate the accuracy of ML models in predicting extubation success.

Methods: A systematic search was performed in PubMed, Embase and CENTRAL up until November 5th, 2024. Studies including mechanically ventilated critically ill adult patients undergoing planned extubation were eligible for this review. The index test was any ML model predicting extubation outcome. Models reporting an area under the receiver operating characteristic curve (AUC) were meta-analyzed, and subgroup analyses were conducted. Risk of bias was assessed using a modified version of the Quality Assessment of Diagnostic Accuracy Studies-Comparative (QUADAS-C) tool, adapted for ML studies.

Results: Twenty-six studies were eligible for systematic review, and 47 ML models from 14 studies (n = 34,322 patients) were included in the meta-analysis. The AUC of all predictive models ranged from 0.59 to 0.98. Pooled AUCs by model type were 0.88 (95% CI: 0.78–0.94) for traditional ML models and 0.85 (95% CI:0.68–0.94) for deep learning models. The best performing ML models of each study had a pooled AUC of 0.90 (95% CI: 0.82–0.95). Study heterogeneity was high, driven by differences in predictor selection and model design, potentially reducing the generalizability of the synthesized evidence.

Conclusions: Machine learning models demonstrate strong accuracy in predicting extubation success and could form an integral part of future weaning strategies. Prospective clinical trials are needed to standardize and validate ML-based prediction models.

P022 Cardiopulmonary adaptation during spontaneous breathing and its association with weaning outcomes: a prospective physiologic study

JT Park 1 , J Kim 2 , YJ Kim 3 , JH Kim 4 , S Kim 2

1 Uijeongbu Saint Mary’s Hospital, Emergency Medicine, Uijeongbusi, Gyeonggido, South Korea, 2 Korea University Ansan Hospital, Critical Care Medicine, Ansan, South Korea, 3 Korea University Ansan Hospital, Division of Pulmonology, Department of Internal Medicine, Ansan, South Korea, 4 Korea University Ansan Hospital, Pumonology and Critical Care Medicine, Ansan, South Korea

Critical Care 2026, 30 (Suppl 1): P022

Introduction: The hemodynamic consequences of transition from positive-pressure ventilation to spontaneous breathing in patients weaning mechanical ventilation are incompletely characterized. We aimed to evaluate the cardiovascular response associated spontaneous breathing trial (SBT) and to determine whether specific hemodynamic parameters are associated with weaning success or failure.

Methods: This single-center prospective observation study included mechanically ventilated adult who met predefined readiness criteria for SBT. Hemodynamic variables, transthoracic echocardiographic parameters, arterial gas analysis results were collected before and during SBT. Successful weaning was defined as maintenance of spontaneous breathing without mechanical ventilation for 72 h.

Results: A total of 186 patients were included, and 130 (69.9%) succeeded weaning. During SBT, respiratory rate increased but PaO 2 /FiO 2 ratio decreased (290 ± 84 vs 254 ± 97, p < 0.001). Hemodynamically, LVEDV (77.5 ± 41.3 vs. 80.2 ± 40.6, p = 0.003) and heart rate (91.0 ± 19.3 vs. 93.1 ± 18.6, p = 0.006) increase, whereas SV was unchanged ( p = 0.708). SBT did not influence LV systolic and diastolic function. When compared by weaning outcome, failed weaning was associated with lower PaO 2 /FiO 2 ratio, higher HR, and smaller LVEDV and SV before SBT. Logistic regression identified PaO 2 /FiO 2 ratio, HR and SV as independent predictors of weaning failure (0.992, 0.985–0.999, 0.031; 1.052, 10.21–1.084, 0.001; 0.948, 95% 0.912–0.986, p = 0.008; OR, 95% CI and p value of PaO 2 /FiO 2 ratio, HR, and SV, respectively), but there was no interaction of hemodynamic change and weaning result in linear mixed model.

Conclusions: SBT induces a characteristic hemodynamic pattern of increased preload, maintained stroke volume, and heart-rate–dependent preservation of cardiac output without overt systolic or diastolic cardiac dysfunction. More integrated cardiopulmonary assessment beyond traditional indices should be considered during SBT.

P023 Evaluating bedside clinical variables and signs to assess extubation failure in ICU patients

BA Andom 1 , CNL Groenland 2 , EJ Wils 3 , EA Dubois 2 , E Ter Bals 4 , TCD Rettig 5 , D Gommers 2 , L Heunks 6 , H Endeman 2 , VJM Baggen 2

1 Myungsung Comprehensive Specialized Hospital, General Practice, Addis Ababa, Ethiopia, 2 Erasmus MC, Intensive Care Medicine, Rotterdam, Netherlands, 3 Franciscus Gasthuis Vlietland, Intensive Care Medicine, Rotterdam, Netherlands, 4 Groene Hart Ziekenhuis, Intensive Care Medicine, Gouda, Netherlands, 5 Amphia Ziekenhuis, Intensive Care Medicine, Breda, Netherlands, 6 Radboud University Medical Center, Intensive Care Medicine, Nijmegen, Netherlands

Critical Care 2026, 30 (Suppl 1): P023

Introduction: Extubation failure occurs in 10–20% of ICU patients despite a successful spontaneous breathing trial (SBT), reflecting the limitations of SBT as a stand-alone readiness assessment. The clinical judgement of a nurse or intensivist likely offers complementary insight into extubation readiness, but it is not a standard component of readiness-to-wean criteria. This study aimed to investigate the prognostic value of readily available clinical variables, nurse-assessed extubation risk and bedside clinical signs in relation to extubation failure.

Methods: Adult ICU patients ventilated ≥ 48 h who underwent an SBT followed by extubation were included in this multicentre cohort. The primary outcome was extubation failure (reintubation ≤ 7 days). Clinical variables (Glasgow Coma Scale (GCS), cough strength and swallowing ability), nurse-assessed extubation risk (5-likert scale) and bedside clinical signs were assessed before SBT or extubation. Bedside clinical signs included; thumbs-up sign (patient gives a thumbs-up after researcher gives a thumb-up), visual pursuit sign (patient follows researcher in the room), crossed-leg sign (patient lies with crossed legs in bed). Univariable logistic regression and multivariable logistic regression analyses were performed.

Results: Of 150 patients, 33 (22%) failed extubation. Mean age was 63 ± 13 years and 61% were male. In univariable analyses, stronger cough strength, intact swallowing ability, and a positive thumbs-up sign were associated with lower odds of extubation failure, while higher nurse-assessed extubation risk was associated with increased odds of failure (Table). GCS and the other bedside signs showed no significant association.

Conclusions: Systematic bedside evaluation of clinical variables and signs offers readily available prognostic information in assessing extubation outcomes. Future studies should further investigate these clinical signs and clarify how they can be integrated into structured extubation assessments.

Table (abstract P023) Results

P024 Correlations between biomarkers, cardiac and lung ultrasound during spontaneous breathing trials

CNL Groenland 1 , EJ Wils 2 , EA Dubois 1 , E Ter Bals 3 , TCD Rettig 4 , D Gommers 1 , L Heunks 5 , H Endeman 6 , VJM Baggen 1

1 Erasmus MC, Intensive Care Medicine, Rotterdam, Netherlands, 2 Franciscus Gasthuis Vlietland, Intensive Care Medicine, Rotterdam, Netherlands, 3 Groene Hart Ziekenhuis, Intensive Care Medicine, Gouda, Netherlands, 4 Amphia Ziekenhuis, Intensive Care Medicine, Breda, Netherlands, 5 Radboud University Medical Center, Intensive Care Medicine, Nijmegen, Netherlands, 6 OLVG, Intensive Care Medicine, Amsterdam, Netherlands

Critical Care 2026, 30 (Suppl 1): P024

Introduction: Cardiac dysfunction, respiratory disease and increased inflammation are potential contributors to extubation failure. Biomarkers, cardiac and lung ultrasound (LUS) can help to identify abnormalities, whereby the correlation between biomarkers and ultrasound may help to further understand the pathophysiological pathways. This study aimed to investigate the correlation of biomarkers with cardiac and lung ultrasound measurements during spontaneous breathing trials (SBT).

Methods: We included patients ventilated ≥ 48 h, undergoing an SBT and extubation in a multicenter cohort study. Blood samples and ultrasound measurements were obtained at start and end of the SBT. Biomarkers included NT-proBNP, hs-TnT, CK-MB, ST-2, galectin-3, Cystatin-C, GDF-15, CA-125, albumin, procalcitonin, IL-6, CRP. Cardiac ultrasound assessed systolic and diastolic function. LUS was performed according to the BLUE protocol, with a maximum LUS score of 18 (max. anterior score 12). Correlations were assessed using Spearman’s rank correlation.

Results: We included 93 patients (mean age 62 ± 14 years, 61% male). Extubation failure occurred in 22%, of whom 76% had extubation failure due to respiratory or cardiac failure. NT-proBNP, hs-TnT, Galectin-3, Cystatin-C had moderate/good significant correlations with LV systolic dysfunction, E/e’, and left atrial area (Figure). NT-proBNP and LUS score showed a moderate significant correlation. Poor correlations were found between ultrasound measurements and inflammatory biomarkers (procalcitonin, CRP, IL-6). Correlations at the end of the SBT were similar.

Conclusions: Several cardiac biomarkers correlated with echocardiographic measurements of systolic and diastolic dysfunction, supporting their shared pathophysiological origin. NT-proBNP showed a modest correlation with LUS score. Cardiac biomarkers and ultrasound measurements may provide complementary information during an SBT, which may facilitate a balanced pathophysiological assessment used to improve extubation failure prediction.

Figure (abstract P024) Correlations. LUS = Lung ultrasound, LA = Left atrial, LV = Left ventricular, TAPSE = Tricuspid annular plane systolic excursion

P025 Effect of sedation on respiratory drive and effort in patients with acute hypoxemic respiratory failure during the early phases of assisted mechanical ventilation

S Giovanazzi

University of Brescia, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, Brescia, Italy

Critical Care 2026, 30 (Suppl 1): P025

Introduction: Patients with acute hypoxemic respiratory failure (AHRF) may have difficulty maintaining optimal inspiratory effort while on assisted mechanical ventilation (AMV). While sedatives can help regulate respiratory drive and effort, deep sedation may negatively affect short and long-term outcomes, making an optimal sedation strategy uncertain. This study aims to investigate the effect of sedation on respiratory drive, effort, transpulmonary driving pressure, and asynchrony rate.

Methods: This is an observational study on AHRF patients in the first 48 h of receiving AMV, with opiod-free sedation. Sedation and respiratory support level were choosed based on clinical practice. We considered 5-min patient segments every 6 h in which sedation and respiratory data were recorded: Patient State Index (PSI) and Richmond Agitation-Sedation Scale (RASS), airway pressure in the first 100 ms (P0.1) and the rate of increase in Pmus over inspiratory time (Pmus, rate = Pmus/∆t), esophageal pressure swing (∆Pes) and esophageal pressure time product (PTPPes). Depending on the outcome distribution, linear and generalized linear mixed effects regression models were applied, adjusted for patient respiratory mechanical characteristics, drug used and ventilator settings.

Results: We analyzed 2809 respiratory breaths of 11 AHRF patients, sedated with either propofol (66.9%) or dexmedetomidine (33.1%).When the PSI increases, P0.1 ( p < 0.001), Pmus, rate ( p = 0.033), ∆Pes ( p = 0.041), PTPPes ( p < 0.036) and ∆PLdyn ( p < 0.001) increase as well while a non-significant decrease in AI was observed (Figure). When considering RASS, there was no evidence of sedation’s effect on drive and effort.

Conclusions: In patients with AHRF, light-moderate sedation can help maintain a low respiratory drive and effort during the early phases of AMV. Compared with RASS, sedation guided by processed EEG appears more effective, as it helps avoid overly deep sedation and supports achieving the appropriate sedation level.

Figure (abstract P025) Effect of sedation when monitored with processed EEG on respiratory variables. Linear and generalized linear mixed effects adjusted for patient respiratory mechanical characteristics and ventilator settings, including pressure support and PEEP

P026 Adaptive ventilation modes reduce length of mechanical ventilation: a systematic review and meta-analysis

PR Tóth 1 , Z Weber 1 , R Aimene 2 , L Dávid 3 , C Turan 1 , P Hegyi 4 , Z Sipos 2 , Z Molnár 1 , A Lorx 1

1 Semmelweis University, Intensive Therapy, Budapest, Hungary, 2 Semmelweis University, Centre of Translational Medicine, Budapest, Hungary, 3 Semmelweis University, Interventional Radiology, Budapest, Hungary, 4 Semmelweis University, Institute of Pancreatic Disease, Budapest, Hungary

Critical Care 2026, 30 (Suppl 1): P026

Introduction: Adaptive modes aim to optimize patient-ventilator synchrony, reduce work of breathing, and potentially decrease staff workload. Despite increasing use, their clinical advantages over conventional protocolized ventilation remain uncertain. Therefore, we investigated whether adaptive modes reduce the duration of ventilation compared to conventional modes.

Methods: We systematically searched MEDLINE, EMBASE, CENTRAL for articles from inception until November of 2024. Randomized and observational studies comparing adaptive and conventional ventilation methods reporting duration of mechanical ventilation (DMV), invasive ventilation duration, weaning and extubation time and success, ventilator-free days, ICU and hospital length of stay (LOS-ICU, LOS-H), and 28-day mortality were eligible for inclusion. Meta-analyses were performed using META and DMETAR packages in R with a random effects model. Heterogeneity was assessed according to the Cochrane Handbook using I 2 and tau 2 . Risk of bias was assessed using ROBINS for observational studies and Rob2 for RCTs. The study was registered to PROSPERO (ID: CRD42024605368).

Results: 46 studies with 4231 patients were included. DMV showed 1.21 days shortening in case of adaptive modes in the pooled result (MD: -1.21 days; 95% CI: -1.80; -0.63) (Figure). Adaptive support ventilation (ASV) shortens the total mechanical ventilation duration (MD: –1.4 days; 95% CI: –2.14; –0.66) and PAV (proportional assist ventilation) shortens it by 1.8 days (MD: -1.81; 95% CI: -2.50; -1.11). In the NAVA (neurally adjust ventilation assist) subgroup we found that it has 2.11 higher odds for successful weaning compared to conventional (OR: 2.11; 95% CI: 1.04; 4.29). Adaptive modes shorten LOS-H (MD: -1.14 days; 95% CI: -1.70; -0.59) and PAV shortens both LOS-ICU (MD: -1.27 days; 95% CI: -2.01; -0.52) and LOS-H (MD: -1.81days; 95% CI: -2.36 to -1.27).

Conclusions: Adaptive ventilation modes, including PAV and ASV, significantly reduce the total duration of mechanical ventilation.

Figure (abstract P026) The total duration of mechanical ventilation in medical ICU patients´ cohort

P027 Assessing diaphragm dysfunction: concordance between the gold standard bilateral anterior magnetic phrenic nerve stimulation, diaphragm ultrasound and maximal inspiratory pressure—a pilot study

R Zangari, R Contarino, S Landini, L Ceresoli, A Bonvini, S Piva, F Rasulo, N Latronico, M Bertoni

Department of Anesthesia, Intensive Care and Emergency, ASST Spedali Civili University Hospital, Università degli Studi di Brescia, Brescia, Italy

Critical Care 2026, 30 (Suppl 1): P027

Introduction: Diaphragmatic dysfunction (DD) contributes to ventilatory impairment and prolonged weaning. Bilateral Anterior Magnetic Phrenic Nerve Stimulation (BAMPS) with Ptr,stim is the diagnostic gold standard, but its use is limited by technical complexity. Simpler bedside measures such as maximal inspiratory pressure (MIP) and ultrasound-derived diaphragmatic thickening fraction (TFdi) assess different physiological domains—global inspiratory strength and diaphragm contractility—but their concordance with BAMPS remains unclear. We aimed to evaluate the concordance of Ptr,stim, MIP and TFdi for diagnosing DD and their ability to predict spontaneous breathing trial (SBT) failure.

Methods: We conducted a prospective study in high-risk adult ICU patients, as defined by Hernández et al. [1], mechanically ventilated ≥ 48 h and fulfilling SBT readiness criteria according to Boles et al. [2]. SBTs were performed with minimal pressure support. During the SBT, each patient underwent three BAMPS-derived Ptr,stim measurements, three TFdi assessments and three MIP maneuvers. Concordance with BAMPS was quantified using percentage concordance, Cohen’s kappa and McNemar’s test. Prediction of SBT failure was evaluated using ROC curves (AUC, 95% CI, Youden index).

Results: 50 patients were included. Concordance with BAMPS was limited: MIP showed 64% concordance (κ = 0.12), while TFdi showed 44% (κ = –0.06) with significant under-detection (McNemar p =0.03) (Figure). Predictive performance for SBT failure was modest, with AUCs of 0.611 (Ptr,stim), 0.629 (MIP) and 0.686 (TFdi), the latter being statistically significant.

Conclusions: Neither MIP nor TFdi showed sufficient concordance with BAMPS to independently diagnose DD and all measures demonstrated limited ability to predict SBT failure. However, because MIP and TFdi reflect distinct physiological domains, their combined use may provide complementary bedside information and support a multimodal approach to diaphragm assessment in critically ill patients.

Figure (abstract P027) Left: Table and mosaic plots indicate a low level of concordance between diaphragm dysfunction identified by BAMPS and DD defined by maximal inspiratory pressure (MIP) and ultrasound (US-TFdi). Both MIP and TFdi show limited concordance with the gold standard. The McNemar test indicates that TFdi has a poor ability to detect diaphragm dysfunction, leading to more false negatives. Right: ROC curves for SBT failure prediction, analyzed using Ptr, stim at BAMPS (blue), MIP (green) or Tfdi (orange)

References Hernández G et al. JAMA 2016;316:1565–1574 Boles JM et al. Eur Respir J 2007;29:1033–56

P029 Low accuracy of detecting ventilatory dyssynchrony using artificial intelligence

V Zvonicek 1 , V Zvonicek Jr. 2 , J Pažout 3 , P Waldauf 3 , M Nemy 4 , M Macik 4 , L Vyslouzilova 4

1 University Hospital Královské Vinohrady, Department of Anaesthesia and Intensive Care Medicine, Prague, Czech Republic, 2 ETH, Zürich, Switzerland, 3 University Hospital Královské Vinohrady, Prague, Czech Republic, 4 Czech Institute of Informatics, Robotics and Cybernetics, Czech Technical University, Prague, Czech Republic

Critical Care 2026, 30 (Suppl 1): P029

Introduction: The aim of the study was to evaluate the precision of the SmartAlert classifiers in detecting ventilatory dyssynchrony. SmartAlert system is a machine learning-based tool designed to enhance the detection of patient-ventilator dyssynchronies (VD) in the intensive care unit (ICU) settings [1]. The system uses state-of-the-art signal processing techniques and deep learning models to analyse data from ventilator screens, capturing and classifying VD, and to predict alarm level. When the alarm threshold is reached, ventilator screen images, along with an analysis report, are sent to physicians’ mobile phones (Figure).

Methods: The study validated the SmartAlert classifier following its implementation into ICU. To evaluate the classifier’s accuracy, 500 ventilator screen images were randomly selected as a sample. The physicians then rated the correctness of the AI-detected assessment of dyssynchronies and ventilation parameters on the selected images. The classifier’s accuracy was calculated for three types of dyssynchronies — double cycling (DC), ineffective effort (IE), and high inspiratory effort (hIE) — and for ventilatory parameters — tidal volume (VTE), respiratory rate) (RR) and peak inspiratory pressure (Ppeak).

Results: The accuracy of SmartAlert in detecting DC, hIE and IE was 62%, 53% and 87%, respectively. The accuracy evaluating VTE, RR and Ppeak was 92%, 94% and 99%, respectively. All dyssynchronies on individual reports were correctly identified in 23% of the reports.

Conclusions: The accuracy of the AI-based assessment of ventilator dyssynchronies is too low to be used in clinical practice.

Acknowledgement: Supported by Grant Ministry of Health, Czech Republic, AZV NU22-06–00625.

Figure (abstract P029) Sample of a ventilator screen image with evaluations performed by the SmartAlert classifier sent to a physician´s mobile phone. DC and hIE dyssynchronies are reported; the true dyssynchronies are hIE and IE. DC is not reported correctly

Reference Pažout J et al. Comput Methods Programs Biomed 2025;269:10892

P030 The LoVe score: development and validation of a bedside clinical index to identify patients at risk for prolonged invasive mechanical ventilation

PA Hilders 1 , L Lijovic 2 , M Otten 1 , L Biesheuvel 1 , A Jagesar 1 , O Sigling 1 , PWG Elbers 1

1 Amsterdam UMC, Amsterdam, Netherlands, 2 University Hospital Center Sestre Milosrdnice, Zagreb, Croatia

Critical Care 2026, 30 (Suppl 1): P030

Introduction: Early management decisions after intubation, such as humidification strategy or initiation of prevention bundles for ventilator-associated pneumonia and delirium, often depend on the expected duration of mechanical ventilation. However, no simple, standardised method exists to support such estimates at the bedside. We aimed to develop and validate the Length of mechanical Ventilation (LoVe) index (Figure), a bedside score to predict prolonged invasive mechanical ventilation beyond 48 h using peri-intubation data.

Methods: We conducted a retrospective cohort study using two large, publicly available ICU databases: AmsterdamUMCdb for model development and internal validation, and MIMIC-IV for external validation. The primary outcome was prolonged IMV, defined as support beyond 48 h or death within 48 h. Two LoVe variants were derived: a ventilator-inclusive version incorporating ventilator settings, and a ventilator-agnostic version without ventilator settings. Predictors identified via logistic regression were discretised into clinically interpretable ranges and summed into an additive score. Clinical utility was assessed using decision curve analysis.

Results: In the cardiac surgery and non-cardiac surgery cohorts, the ventilator-inclusive LoVe index achieved AUROC scores of 0.82 and 0.75, respectively. The ventilator-agnostic version reached 0.72 in the non-cardiac surgery cohort. Validation in MIMIC-IV yielded 0.71 and 0.68 for the ventilator-inclusive version, and 0.71 and 0.65 for the ventilator-agnostic index. Decision curve analysis demonstrated that both LoVe indices provided meaningful clinical utility.

Conclusions: The LoVe index provides a simple, interpretable bedside tool to estimate the likelihood of prolonged IMV early after intubation, showing consistent external validity and potential to support early ICU decision-making.

Figure (abstract P030) (A) Scoring rubric for the ventilator-inclusive LoVe index, with point values assigned to clinically defined ranges of respiratory rate, heart rate, FiO 2 , PEEP, and pH. Higher scores reflect higher predicted risk of prolonged invasive mechanical ventilation (IMV). (B) Calibration curve mapping LoVe scores to the estimated probability of prolonged IMV

P031 Pulmonary melioidosis and lung ultrasound: a diagnostic challenge

PY Gonzalez Noris

ISSSTE, ICU, La Paz, Mexico

Critical Care 2026, 30 (Suppl 1): P031

Introduction: Pulmonary melioidosis, which is caused by Burkholderia pseudomallei , presents significant diagnostic challenges due to its different clinical findings, often mimicking other infections or malignancies. [1]. The present case study attempts to enhance the efficient use of lung ultrasound as a diagnostic tool while also emphasizing the limitations of less comprehensive imaging methods [2].

Methods: This is a case report with detailed clinical data, including lung ultrasound and microbiological culture. Informed consent was obtained.

Results: A 23-year-old male exhibited a one-month history of cough, fever, and dyspnea. His past medical history included diabetes mellitus, which is a known risk factor for severe melioidosis [3]. A bronchial secretion culture was obtained; Burkholderia pseudomallei grew. The first examination with a 12-zone lung ultrasound revealed diffuse B-lines, subpleural consolidations, and dynamic air bronchograms, indicative of significant inflammatory alterations and inadequate alveolar ventilation. Peripheral nodules were also visible [Figure]. Additionally, we are finding hypoechoic images in the spleen.

Conclusions: This case points out the essential role of lung ultrasound in the diagnosis of pulmonary melioidosis, especially in resource-limited settings where advanced imaging may be unavailable. Likewise, lung ultrasound offers a noninvasive, radiation-free, and cost-effective method for assessing disease progression and treatment effectiveness in these complex cases. This technique significantly enhances early detection and facilitates timely initiation of treatment, resulting in improved patient outcomes in regions where melioidosis is prevalent.

Figure (abstract P031) 12-zone lung ultrasound showing different findings in pulmonary melioidosis

Acknowledgement: Written consent to publish was received from the patient's next of kin.

References Yang X et al. Trans R Soc Trop Med Hyg 2025;119:125–134 Nguyen‐Ho L et al. AME Med J 2025;10:23 Dao-Thi NH et al. J Glob Infect Dis 2022;14:87–89

P032 Ultrasound evaluation of the parasternal intercostal muscles and diaphragm activity post-operative mediastinal tumor with unilateral diaphragmatic dysfunction

WEI Wu, FEI Han

Zhongshan hospital, Fudan University, Department of Critical Care, Shanghai, China

Critical Care 2026, 30 (Suppl 1): P032

Introduction: Few studies focus on the compensatory role of the intercostal muscles in respiratory effort in the patients with post-operative unilateral diaphragmatic dysfunction using bedside ultrasound due to phrenic nerve injury.

Methods: This prospective observational study included patients who underwent extended resection of mediastinal tumors and were subsequently admitted to the SICU. Prompted completion of baseline ultrasound assessments within 12 h of ICU admission post-operation to evaluate bilateral diaphragm excursion and thickening fraction, as well as intercostal muscle thickening fraction. For patients during their ICU stay, kindly record diaphragm and intercostal muscle ultrasound data upon discharged the ICU. The primary outcome of this study is the occurrence of postoperative respiratory failure requiring respiratory support, which includes high-flow oxygen, non-invasive ventilation, and intubation.

Results: A total of 40 patients (23 males, average age 48.6 years) were ultimately included in the final analysis. Within this cohort, 21 received respiratory support and 19 received conventional oxygen therapy (COT). At ICU admission, the respiratory support group exhibited higher TFic, RR, and TFic/TFdi, which decreased significantly at ICU discharge. In contrast, the COT group had slight increases in TFic and RR at ICU discharge compared to ICU admission, with both groups showing similar TFic, RR, and TFic/TFdi at discharge. Both groups showed an increasing trend in bilateral TFdi.

Conclusions: This study uncovered that 50% of patients with diaphragm dysfunction following surgery for mediastinal tumors required postoperative respiratory support treatment (RS). Upon admission, the respiratory treatment group displayed higher TFic, RR, and TFic/TFdi, but these indicators appeared to converge between the two groups at discharge. The trend for TFdi was similar in both groups, showing an increase from baseline to discharge, with the respiratory treatment group having a higher baseline TFdi.

P033 Polysulfide-mediated lung protection in ARDS: effects and mechanisms in cell and mouse models

E Kanemaru, K Takeyama, A Sato, K Tojo, T Goto

Yokohama City University School of Medicine, Anesthesiology and Critical Care Medicine, Yokohama, Japan

Critical Care 2026, 30 (Suppl 1): P033

Introduction: Acute respiratory distress syndrome (ARDS) lacks effective pharmacological therapy, and new therapeutic strategies are urgently needed. Sulfur metabolism is involved in oxidative stress and inflammatory responses. Polysulfides, which contain sulfane sulfur (S 0 ), exhibit versatile reactivity as nucleophiles and electrophiles [1]; however, their potential effects in ARDS remain unclear. This study aimed to evaluate the lung-protective effects of polysulfides and elucidate their underlying mechanisms.

Methods: In an in vitro alveolar epithelial cell injury model by co-culture of isolated neutrophils and LPS, the effects of sodium trisulfide (Na 2 S 3 ) and sodium tetrasulfide (Na 2 S 4 ) on cell viability, S 0 release quantified by SSP4 fluorescence, expression of GDF15, Slc7a11, and inflammatory cytokines quantified by qPCR, and maximal mitochondrial respiration measured by Seahorse were evaluated. In vivo, Na 2 S 3 was administered intraperitoneally to LPS-induced ARDS mice, and inflammatory cell counts in the bronchoalveolar lavage (BAL) were analyzed.

Results: Na 2 S 3 improved cell viability in a dose-dependent manner, with Na 2 S 4 demonstrating similar effects (Figure, panels A, B). Both agents showed greater cytoprotective effects than sodium sulfide (Na 2 S), lacking S 0 (Figure, panel B). The level of S 0 inside MLE12 cells increased with increasing concentration of Na 2 S 3 and Na 2 S 4 (Figure, panel C). Na 2 S 3 increased GDF15 expression and significantly reduced Slc7a11 and inflammatory cytokine expression (IL-1β, IL-6, TNF-α). Maximal mitochondrial respiratory capacity was dose-dependently restored (Figure, panel D). In ARDS mice, Na 2 S 3 significantly reduced total inflammatory cell counts in BAL (Figure, panel E).

Conclusions: Polysulfides exerted lung-protective effects in ARDS through protection of mitochondrial function, anti-inflammatory effects partially mediated by GDF15, and suppression of ferroptosis pathways. These findings suggest polysulfides as promising therapeutic candidates for ARDS.

Figure (abstract P033) Results. BAL, bronchoalveolar lavage; LPS, lipopolysaccharide; MLE12, a murine alveolar epithelial cell; N, neutrophils; Na 2 S, sodium sulfide; Na 2 S 3 , sodium trisulfide; Na 2 S 4 , sodium tetrasulfide; OCR, oxygen consumption rate; PBS, phosphate-buffered saline

Reference Kanemaru E et al. Pharmacol Ther 2025;266:108787.

P034 Age and immune status modify the harm of high arterial oxygen partial pressure level in ARDS: a causal forest analysis of the ARDSnet cohort

S Hu, Y Yang

Zhongda Hospital, School of Medicine, Southeast University, Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Nanjing, China

Critical Care 2026, 30 (Suppl 1): P034

Introduction: The relationship between arterial oxygen partial pressure (PaO₂) and mortality in ARDS is unclear. Heterogeneity in the association between high PaO₂ and mortality across patient subgroups remains uncertain. The relationship between arterial oxygen partial pressure (PaO₂) and mortality in ARDS is unclear. Heterogeneity in the association between high PaO₂ and mortality across patient subgroups remains uncertain.

Methods: A cohort of 4,540 ARDS patients from the ARDSnet database was analyzed. Restricted cubic splines identified 98.5 mmHg as a potential threshold in the association between day-1 PaO₂ and 28-day mortality. The conditional average treatment effect (CATE) of high PaO₂ (≥ 98.5 mmHg on day 1) on mortality was estimated using causal forest models, adjusting for FiO₂, PEEP, illness severity, comorbidities, and physiological variables, with overlap weighting to ensure valid inference.

Results: High PaO₂ was associated with a 3.5% higher absolute risk of 28-day mortality. The effect varied by age and immune status: CATE increased with age, reaching 0.045 (95% CI: 0.035–0.055) in patients > 65 years (Figure). Immunosuppressed individuals showed greater risk, particularly when elderly (interaction p = 0.049). Older immunosuppressed patients had nearly twice the risk difference compared with younger, immune-competent counterparts.

Conclusions: The mortality risk associated with high PaO₂ in ARDS is modified by age and immune status. Older immunosuppressed patients are especially vulnerable, supporting individualized oxygen targets in this high-risk group.

Figure (abstract P034) Average CATE by age and immune subgroups

P035 Power, duration and compliance: reframing the risk of ventilatory induced lung injury with the RAMP score

L Lijovic 1 , P Hilders 2 , T Radocaj 1 , M Siranovic 1 , PW Elbers 3

1 Clinical Hospital Centre Sestre Milosrdnice, Intensive Care, Zagreb, Croatia, 2 Amsterdam UMC, Intensive Care, Amsterdam, Netherlands, 3 Amsterdam UMC, Adult Intensive Care, Amsterdam, Netherlands

Critical Care 2026, 30 (Suppl 1): P035

Introduction: Static thresholds for mechanical power may not prevent ventilator-induced lung injury because risk depends on exposure duration and the underlying lung compliance. We wanted to quantify how mechanical power intensity and exposure duration interact with lung compliance to predict oxygenation changes consistent with acute respiratory distress syndrome (ARDS) worsening or 14-day mortality.

Methods: A retrospective analysis of mechanically ventilated adults with moderate to severe ARDS in two large intensive care databases was performed. Time-dependent Cox proportional hazards models stratified by lung compliance estimated the hour-specific associations of immediate exceedance and cumulative time above mechanical power thresholds with the primary outcome. Estimated effects were integrated into a risk-adjusted mechanical power (RAMP) score, which was then evaluated as a predictor of ARDS worsening or 14-day mortality using XGBoost.

Results: Among 2,150 ARDS patients risk, from mechanical power exposure was dictated by lung compliance: in higher-compliance lungs, risk followed a dose–response pattern, with immediate hazard beginning at 10 J/min (HR≈1.04) and cumulative harm amplifying significantly over time (Figure). Conversely, for low-compliance patients, risk was confined to a narrow power band (11–20 J/min) without evidence of cumulative harm. With RAMP score as a predictor of outcome XGBoost yielded an area under the receiver operating characteristic curve of 0.874 (precision 0.807, recall 0.494; F1 0.612); PaO 2 /FiO 2 remained the dominant predictor.

Conclusions: A single ‘safe’ mechanical power threshold is insufficient for guiding ventilation; the risk of lung injury is governed by a dynamic interplay of power intensity, duration, and the patient’s lung compliance. The risk-adjusted mechanical power score unifies these factors into a time-varying, clinically interpretable metric that warrants prospective validation for personalized ventilator management.

Figure (abstract P035) Heatmaps of the predicted hazard ratio in hour h (HRtotal(h) = HRimmediate × HRcumulative (h-1) by compliance group, with (A) compliance above the cohort median (32.6 mL/cmH 2 O) and (B) compliance below the cohort median. Each panel shows threshold on the y axis and cumulative hours spent above that threshold on the x axis. Dotted line represents cutoff of less than 100 cases assumed necessary for a reliable analysis

P036 Pulmonary effects of two lung-protective ventilation strategies in an experimental swine model of ARDS

F Rodríguez, M Pécora, R Beltramelli, A Cattivelli, A Guerrero, MJ García, AL Suárez, C Morais, P Alzugaray, M Angulo

Hospital de Clinicas, Laboratorio de Exploración Funcional Respiratoria, Montevideo, Uruguay

Critical Care 2026, 30 (Suppl 1): P036

Introduction: Mechanical ventilation (MV) can worsen lung injury in acute respiratory distress syndrome (ARDS), and which ventilation strategy better reduces this damage still remains nuclear.

Methods: Lung injury was induced in pigs using a two-hit model consisting of bronchoalveolar lavages followed by injurious MV. Animals were randomized to either the ARDS Network strategy (ARDSNet, n = 8) or the Open Lung Approach (OLA, n = 8). In the ARDSNet group, PEEP was set according to the low PEEP/FiO₂ table. In the OLA group, PEEP was guided by electrical impedance tomography (EIT) after a recruitment maneuver, selecting the level that minimized both alveolar collapse and overdistension. Ventilation continued for 6 h (T0-1–2-3). A Control group (n = 6) without injury received 6 h of protective ventilation with EIT-guided PEEP. Ventilatory mechanics, EIT (ventilation and perfusion, V/Q), and blood gases were recorded, followed by lung histology. Data (mean ± SEM) were analyzed using repeated-measures ANOVA.

Results: The OLA group maintained higher PaO₂/FiO₂, lower driving pressure, and lower shunt fraction ( p < 0.05), approaching Controls (Figure, panels A–D). Optimal V/Q distribution was 63% in Controls, 50% in OLA, and 36% in ARDSNet ( p < 0.05). ARDSNet showed dorsal ventilation loss with ventral shift, whereas OLA preserved more homogeneous ventilation. Perfusion maps revealed reduced dorsal perfusion and ventral inhomogeneity in ARDSNet, while OLA maintained greater dorsal perfusion and overall homogeneity. In V/Q maps, OLA showed better matching and less shunt and dead space than ARDSNet (Figure, panel E). Wet-to-dry ratio and septal thickness were lower in Controls ( p < 0.05), with no differences between OLA and ARDSNet. Air-to-tissue ratio was higher in Controls and OLA than in ARDSNet ( p = 0.06) (Figure, panel F).

Conclusions: OLA was associated with better gas exchange, improved V/Q matching, more favorable ventilatory mechanics, and reduced histological lung injury.

Figure (abstract P036) Summary of results

P037 Accuracy of volume, pressure and oxygen delivery by bellavista ventilators in use in the pediatric and adult intensive care unit: a quality control study

A Waldmann 1 , J Kelly 2 , A Gundlapalli 3 , J Burren 2

1 ZOLL Medical, Clinical Affairs, Chelmsford, USA, 2 University Children´s Hospital, Zurich, Switzerland, 3 ZOLL Medical USA, Chelmsford, USA, 2 University, Children´s Hospital, Zurich, Switzerland

Critical Care 2026, 30 (Suppl 1): P037

Introduction: Invasive ventilation is the most common organ support in pediatric and adult ICUs, used for a variety of clinical conditions in patients of all ages. Research has shown that adjusting ventilator parameters according to individual patient requirements can minimize the risk of ventilator-induced lung injury [1]. Regardless of the strategy used to set ventilation parameters at the bedside, clinicians need to be able to rely on the accuracy of the ventilator delivering the set targets to ensure effective and safe mechanical ventilation. The aim of this study is to assess the accuracy of set ventilatory parameters delivered by the bellavista™ ventilator (ZOLL Medical).

Methods: This prospective observational study ( NCT05383651 ), approved by the local ethics committee, included pediatric and adult patients who received ≥ 12 h of non-invasive or invasive ventilation with the bellavista ventilator. Median differences between set and measured values for PIP, PEEP, tidal volume, and flow rate were calculated.

Results: 338 subjects were analysed, with a median ventilation duration of 58.3 h (IQR 25.1–122.7). Results are summarized in the Table.

Conclusions: The bellavista ventilator delivers pressure, volume and flow rates with minimal deviation from set targets.

Reference Nieman GF et al. Intensive Care Med Exp 2017;5:8

Table (abstract P037) Median difference between set and delivered pressure, volume and flow *measured during pressure-controlled ventilation.

P038 A deep learning approach using chest X-rays for assessing oxygenation status in mechanically ventilated patients

YC Jeong 1 , C Kang 1 , LR Lim 2 , HN Lee 2 , HG Ryu 1

1 Seoul National University Hospital, Department of Critical Care Medicine, Seoul, South Korea, 2 Seoul National University Hospital, Department of Anesthesiology and Pain Medicine, Seoul, South Korea

Critical Care 2026, 30 (Suppl 1): P038

Introduction: Most of deep learning algorithm available are based on standardized images. Chest X-ray (CXR) images in critically ill patients diversely vary and thus challenging to apply general deep learning programs for clinical aid. This study aims to design deep learning algorithm task to predict change in clinical status of intubated intensive care unit (ICU) patients from CXRs.

Methods: In this retrospective model development study, we first trained a publicly available deep learning model including a pooled dataset of CXRs (n = 373,343) from 11,438 ICU patients. After self-supervised learning, each X-ray was paired with patients’ laboratory data and was trained to differentiate between normal (PaO 2 /FiO 2 > 300) and abnormal (PaO 2 /FiO 2 < 300) CXRs. The model was tested in fully-supervised learning in three groups: for training (n = 3,879), for validation (n = 453), and for internal testing (n = 423). The downstream task was to predict whether the CXR improved or deteriorated between two consecutive CXR images. We conducted the downstream tasks in three distinct phases of increasing complexity. Model performance was evaluated using accuracy, sensitivity, specificity, F1 score, and generated a receiver operating characteristic (ROC) curve with its corresponding area under the curve (AUC) to assess its ability to capture changes across the entire P/F ratio distribution.

Results: The ability of the X-ray model to detect change in four distinct categories of P/F ratio resulted in an AUROC of 0.948, accuracy of 0.957, sensitivity of 95.7%, specificity of 83.3%, and F1 score of 0.898. The model’s performance exhibited an inverse relationship with task complexity, AUROC and accuracy was 0.711, 0.635 for task 2, and 0.658, 0.621 for task 3, respectively.

Conclusions: A deep learning model can be trained to predict X-ray changes correlated with P/F ratio. Further research and external validation and fine-tuning is needed to support clinical practice in predicting oxygenation of mechanical ventilated patient in ICU.

P039 Association between organ perfusion pressure and mortality in older patients with ARDS

K Gkirgkiris 1 , G Konstantinou 1 , D Tsilivarakis 1 , S Theodosis 1 , AM Manousaki 1 , I Siempos 2

1 National and Kapodistrian University of Athens Medical School, Athens, Greece, 2 National and Kapodistrian University of Athens Medical School, First Department of Critical Care Medicine and Pulmonary Services, Athens, Greece

Critical Care 2026, 30 (Suppl 1): P039

Introduction: Organ perfusion pressure, defined as the difference between mean arterial pressure and central venous pressure, may be used for personalized hemodynamic management of critically ill patients, including those with acute respiratory distress syndrome (ARDS) [1]. We explored whether the association between baseline organ perfusion pressure and mortality depends on age.

Methods: We performed a secondary analysis of individual patient-level data from six ARDS Network and PETAL Network randomized controlled trials [2–7]. We conducted splines regression analyses that included an interaction term between organ perfusion pressure and age. Both organ perfusion pressure and age were treated as continuous variables.

Results: 3046 patients with ARDS were included. Organ perfusion pressure was independently associated with 90-day all-cause mortality ( p = 0.022). Their association was non-linear, specifically U-shaped. The association between organ perfusion pressure and mortality depended on age ( p = 0.018). As age increased, the range of organ perfusion pressure values associated with lower mortality (i.e., the U-shaped “valley”) appeared narrower (Figure).

Conclusions: As age increases, the range of organ perfusion pressure values associated with lower mortality becomes narrower. This finding suggests that advanced hemodynamic monitoring may be required especially for older patients.

Figure (abstract P039) Association between organ perfusion pressure and mortality depended on age. As age increased, the range of organ perfusion pressure values associated with lower mortality (i.e., the U-shaped “valley”) appeared narrower

References De Backer D et al. Crit Care 2022;26:372 Brower RG et al. N Engl J Med 2004;351:327–36 Wiedemann HP et al. N Engl J Med 2006;354:2564–75 Matthay MA et al. Am J Respir Crit Care Med 2011;184:561–8 Rice TW et al. JAMA 2012;307:795–803 Truwit JD et al. N Engl J Med 2014;370:2191–200 National Heart, Lung, and Blood Institute PETAL Clinical Trials Network. N Engl J Med. 2019;380:1997–2008

P040 Bedside measurement of exhaled nitric oxide in mechanically ventilated patients: feasibility, reproducibility, and association with lung injury phenotypes

H Wang, MING Zhong

Zhongshan Hospital, Fudan University, Department of Critical Care Medicine, Shanghai, China

Critical Care 2026, 30 (Suppl 1): P040

Introduction: Exhaled nitric oxide (FeNO) is a noninvasive biomarker of airway and alveolar inflammation, yet its performance in mechanically ventilated adults and its ability to differentiate early aspiration pneumonitis (AP) from acute respiratory distress syndrome (ARDS) remain unclear.

Methods: We prospectively measured FeNO using online chemiluminescence in mechanically ventilated ICU patients. Measurement reproducibility was assessed using paired FeNO recordings obtained 3–5 min apart. FeNO levels were compared among postoperative controls, early AP, and ARDS. Diagnostic performance for distinguishing AP from ARDS was evaluated using receiver operating characteristic (ROC) analysis.

Results: Fifty mechanically ventilated patients underwent repeated FeNO assessment, demonstrating excellent reproducibility (bias − 0.055 ppb; limits of agreement − 0.91 to 0.80 ppb; ICC 0.978) (Figure). FeNO levels differed significantly across clinical groups: postoperative controls showed low baseline FeNO, AP patients exhibited markedly elevated levels, while ARDS patients had the lowest concentrations ( p < 0.0001). FeNO showed outstanding discrimination between AP and ARDS, yielding an AUC of 0.975. The optimal cutoff of 3.17 ppb provided sensitivity 0.886 and specificity 0.971.

Conclusions: FeNO can be measured reliably in mechanically ventilated adults and demonstrates distinct patterns across postoperative controls, early aspiration pneumonitis, and ARDS. A FeNO threshold of 3.17 ppb accurately differentiates AP from ARDS, suggesting potential clinical utility for early phenotype identification and respiratory injury stratification.

Figure (abstract P040) Reproducibility of FeNO measurement, group differences, and diagnostic performance for differentiating aspiration pneumonitis (AP) from ARDS. (A) Bland–Altman plot. (B) Comparison of FeNO levels among postoperative controls, AP, and ARDS patients. (C) ROC curve evaluating the diagnostic accuracy of FeNO for distinguishing ARDS from AP

P041 The impact of autoimmune diseases on the development and outcomes of acute respiratory distress syndrome: a retrospective cohort study

YH Ni, N Shi, H Chen, HB Qiu

Zhongda Hospital, Department of Critical Care Medicine, Nanjing, China

Critical Care 2026, 30 (Suppl 1): P041

Introduction: Patients with autoimmune diseases (AIDs) have dysregulated innate immunity, potentially increasing ARDS susceptibility [1]. Given ARDS heterogeneity and inconsistent data on the prognosis of AIDs [2], this study aimed to determine the association between AIDs and ARDS and to identify distinct ARDS phenotypes incorporating underlying autoimmune characteristics.

Methods: This retrospective observational study utilized the MIMIC-IV database as the derivation cohort (n = 9282). The validation cohort (n = 506) was based on the Chinese Database in Intensive Care (CDIC), which comprises data from ICU patients at Zhongda Hospital. The association between AIDs and ARDS was analyzed, and ARDS immune phenotypes were identified through consensus K-means clustering.

Results: AIDs were independently associated with ARDS (OR = 1.30, p = 0.032). However, among patients who developed ARDS, pre-existing AIDs were not independently associated with 28-day in-hospital mortality. Cluster analysis revealed two distinct ARDS phenotypes: Phenotype 1 with severe organ dysfunction and higher mortality (36.7% vs. 18.5%, HR:0.44 (0.37–0.52), p < 0.001), and Phenotype 2 characterized by a higher prevalence of AIDs, milder inflammation, and significantly lower mortality (Figure). Treatment responses were heterogeneous; corticosteroid use was associated with increased mortality in both phenotypes, while disease-modifying antirheumatic drugs (DMARDs) were linked to significantly reduced mortality in the hyperinflammatory Phenotype 1 (13.7% vs. 33.2%, p = 0.006). These key findings were partially validated in the independent validation cohort.

Conclusions: Pre-existing AIDs increase the risk of ARDS, but the prognosis is determined by the specific immune phenotype, not the underlying autoimmune condition itself. These findings underscore the potential for phenotype-guided therapy to improve outcomes.

Figure (abstract P041) Clinical characteristics and prognosis of different ARDS phenotypes

References Place DE et al. Curr Opin Immunol 2020;67: 95–105 Grainger R et al. Nat Rev Rheumatol 2022;18:191–204

P042 Inhaled nitric oxide reduces mortality in severe ARDS with pulmonary hypertension: meta-analysis of 6 RCTs

V Gherghina 1 , I Cîndea 1 , A Balcan 2 , D Costea 3 , R Popescu 3

1 SCJU Constanta, ATI, Constanta, Romania, 2 Facultatea de Medicin 259, ATI, Constanta, Romania, 3 Facultatea de Medicin259, Chirurgie, Constanta, Romania

Critical Care 2026, 30 (Suppl 1): P042

Introduction: Right ventricular failure from pulmonary hypertension (mPAP > 35 mmHg) complicates 25–35% of severe ARDS with 60–80% mortality. Large trials (EOLIA, ROSE) showed no mortality benefit from inhaled nitric oxide (iNO) in unselected ARDS populations. We hypothesized iNO benefits the PH-ARDS phenotype through selective pulmonary vasodilation and RV protection.

Methods: Systematic review (PROSPERO; PRISMA 2020) of RCTs comparing iNO (5–40 ppm) versus placebo/standard care in mechanically ventilated severe ARDS (PaO 2 /FiO 2 ≤ 150) with confirmed PH (mPAP > 35 mmHg by echocardiography/Swan-Ganz). Searched MEDLINE, Embase, Cochrane, ClinicalTrials.gov through November 2025. Primary outcome: 28-day mortality. Secondary: mPAP change at 24h, PaO 2 /FiO 2 improvement, RV function (RV/LV ratio), ventilator-free days. Random-effects meta-analysis with pre-specified subgroups by PH severity (mPAP > 40 vs 35–40 mmHg). Trial sequential analysis, RoB 2.0, GRADE assessment.

Results: Six RCTs included (n = 389; iNO 194, control 195). Baseline: PaO 2 /FiO 2 112 ± 22 mmHg, mPAP 40.2 ± 4.8 mmHg. iNO significantly reduced 28-day mortality: RR 0.81 (95%CI 0.66–0.99; I2 = 24%; NNT = 11). Absolute mortality: 38.1% versus 47.2%; ARR 9.1%. Secondary outcomes: mPAP reduction -8.2 mmHg (-11.4 to -4.9), PaO 2 /FiO 2 improvement + 42 mmHg (+ 28 to + 56), RV/LV ratio -0.18 (-0.26 to -0.10), ventilator-free days + 3.8 (+ 1.9 to + 5.7). Severe PH subgroup (mPAP > 40, n = 218): greater mortality reduction, RR 0.72 (0.56–0.92; NNT = 6); ARR 13.5%. TSA confirmed adequate power. Low bias risk (5/6 trials), no publication bias. Methemoglobinemia < 2%. GRADE: High certainty for hemodynamic outcomes, moderate for mortality.

Conclusions: iNO significantly reduces mortality in severe ARDS with PH (NNT = 11), with dose–response favoring mPAP > 40 (NNT = 6). Echo-guided phenotyping enables precision therapy, transforming previously unsuccessful intervention into targeted life-saving strategy, challenging current guidelines against routine iNO use.

P043 Independent and additive effects of inhaled nitric oxide and prone positioning on oxygenation in COVID-19 ARDS

H Wang, M Zhong

Zhongshan Hospital, Fudan University, Department of Critical Care Medicine, Shanghai, China

Critical Care 2026, 30 (Suppl 1): P043

Introduction: Inhaled nitric oxide (iNO) and prone positioning (PP) are commonly used to improve oxygenation in acute respiratory distress syndrome (ARDS), but their combined physiological effects in COVID-19 ARDS (CARDS) remain unclear. We evaluated the independent and additive effects of iNO and PP and explored predictors of treatment responsiveness using electrical impedance tomography (EIT).

Methods: In this prospective study, 24 mechanically ventilated CARDS patients underwent four sequential phases: baseline supine (SP), iNO 15–20 ppm in supine for 1 h (SPNO), prone without iNO for 1 h (PP), and combined PP + iNO for 1 h (PPNO). At each phase, gas exchange, ventilatory parameters, and EIT-derived ventilation–perfusion indices were recorded. Responders were defined by ≥ 20% improvement in PaO₂/FiO₂. A mixed-effects model assessed main and interaction effects.

Results: Both iNO and PP significantly improved oxygenation (Figure). PaO₂/FiO₂ increased from SP to SPNO and from SP to PP, and reached its highest level during PPNO. No interaction effect was detected, indicating additive rather than synergistic benefits. Early oxygenation response to iNO strongly predicted subsequent PP responsiveness (AUC 0.984). EIT showed no consistent phase-dependent changes, but a higher proportion of unmatched units after iNO was associated with mortality (AUC 0.786).

Conclusions: In CARDS, iNO and PP independently improve oxygenation, with additive effects when combined. Early PaO₂/FiO₂ response to iNO may serve as a simple bedside predictor of PP efficacy, supporting individualized treatment strategies. EIT-derived unmatched units following iNO may provide prognostic information.

Figure (abstract P043) Changes in oxygenation (PaO₂/FiO₂ ratio) during sequential application of inhaled nitric oxide (iNO) and prone positioning (PP). PaO₂/FiO₂ values are shown at four consecutive study phases: baseline in the supine position (0h, SP), 1 h of inhaled nitric oxide in the supine position (1h, SPNO), 1 h after transition to the prone position with iNO discontinued (2h, PP), and 1 h of combined prone positioning and iNO (3h, PPNO). Each line represents an individual patient (n = 24)

P044 Epitranscriptomic insights into acute respiratory distress syndrome

A Bagul 1 , L Bilonda Mutala 2 , A Arco Hierves 2 , N Libert 1 , J Duranteau 1 , A Harrois 1 , R Bechara 1 , A Huertas 3

1 Paris-Saclay University DYNAMIC lab, Le Kremlin-Bicêtre, France, 2 Paris-Saclay University IMVAHB/IDMIT, Le Kremlin-Bicêtre, France, 3 Paris-Saclay University DYNAMIC lab, Medecine, Le Kremlin-Bicêtre, France

Critical Care 2026, 30 (Suppl 1): P044

Introduction: Acute respiratory distress syndrome (ARDS) is a complex and severe syndrome with high mortality, characterized by dysregulated inflammation and disruption of lung microvascular barrier, but the underlying mechanisms are still unclear. Inflammatory genes can be induced by promoter regulation but also by post-transcriptional control of mRNA through RNA methylation of adenosine at the 6th nitrogen position (m 6 A) by methyltransferases (METTL3 and METTL14), demethylases and RNA binding proteins. The role of m 6 A machinery in ARDS is not known and we are questioning here whether lung epitranscriptomic changes are present in ARDS and whether m 6 A signaling pathway is involved in this dysregulated inflammatory response.

Methods: Mice were subjected to nasal instillation of hydrochloric acid (HCl; 2 mL/Kg)-induced acute lung injury. Two hours later, lungs were removed and compared to untreated mice (each group n = 4). Results are expressed as mean ± standard error of the mean (SEM) with a statistical significance for Student’s t-test at p < 0005.

Results: HCl-treated mice displayed a significant increase in both lung wet-to-dry weight ratio and inflammatory triggers mRNA expression, such as TNF-a and CCL2, demonstrating the presence of lung edema and dysregulated inflammation, compared to controls. Interestingly, we found a significant decrease in the expression of the m 6 A writer Mettl14 in HCl-treated mice compared to controls (1.12 × 10 –2 ± 4.8 × 10 –4 and 1.15 ± 5.1 × 10 –4 respectively, p < 0.05).

Conclusions: Our findings indicate a notable reduction in m 6 A writer Mettl14 expression in HCl-treated mice lungs compared to controls. Such alterations may affect the whole RNA methylome and hence differentially regulate inflammatory gene expression implicated in ARDS pathogenesis. Further studies are needed to investigate the role of a novel RNA methylation m 6 A in ARDS. Epitranscriptomic marks can therefore represent future therapeutic targets for this severe syndrome.

P045 Electrical impedance tomography versus transpulmonary pressure for personalized positive end-expiratory pressure titration in moderate to severe acute respiratory distress syndrome with intra-abdominal hypertension

Y Wu, C Peng, X Zou, Y Shang

Department of Critical Care Medicine, Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China

Critical Care 2026, 30 (Suppl 1): P045

Introduction: This study aimed to identify optimal PEEP levels by electrical impedance tomography (EIT) compared with transpulmonary pressure in patients with moderate-to-severe ARDS complicated by IAH, and to evaluate the corresponding physiological effects of these PEEP regimens.

Methods: This is a single-center, randomized cross-over study. Thirteen patients diagnosed with moderate-to-severe ARDS and IAH (intra-abdominal pressure ≥ 12mmHg) were enrolled. The baseline ventilator settings were volume-controlled (VT = 6 ml/kg/PBW) mode, with PEEP set with the low FiO 2 -PEEP table recommended by the ARDS Network. Patients were randomly assigned to sequentially undergo PEEP titration guided by EIT or end-expiratory transpulmonary pressure (PtpE) greater than 0 cmH 2 O. We collected physiological data by EIT after 30 min of volume-controlled ventilation at baseline and at respective optimal PEEP level to evaluate the resultant physiological effect.

Results: The median PaO 2 /FiO 2 ratio of 13 enrolled patients was 145 ± 42mmHg and median PEEP was(10 ± 3cmH 2 O) at baseline. The level of PtpE-guided PEEP was significantly higher than EIT-guided PEEP (22 ± 6 cmH 2 O vs 16 ± 3 cmH 2 O, p < 0.001). EIT analysis indicated that PtpE-guided PEEP improved dorsal ventilation% compared with EIT-guided PEEP (38.7% ± 12.0% vs 30.8% ± 11.3%, p = 0.006). The PtpE-guided PEEP decreased global and dorsal shunt% compared with baseline (3.2% [1.6%—6.1%] vs 7.5% [6.6% -13.3%], p = 0.003, and 5.4% [3.5%-11.1%] vs 9.1% [7.6%-18.8%], p = 0.008). PtpE-guided PEEP also decreased ventral dead space% compared with baseline (2.2% [0.9%—6.8%] vs 4.1% [2.3%- 9.9%], p = 0.032). Moreover, PtpE-guided PEEP improved dorsal matching% compared with EIT-guided PEEP (34.8% ± 6.3% vs 31.6% ± 7.4%, p = 0.039).

Conclusions: In patients with moderate-to-severe ARDS complicated by IAH, the PEEP level titrated by PtpE was significantly higer compared with EIT or a conventional lower PEEP-FiO 2 table, and PtpE-guided PEEP significantly improved ventilation-perfusion (V/Q) matching.

P047 Efficacy of combined EIT-derived ventilation and pulsatility/perfusion signals for continuous monitoring and differentiation of lung and pleural pathologies

B Ferro 1 , M Pillitteri 1 , L Camporota 2 , FS Taccone 3

1 Spedali Riuniti Livorno ATNO, Department of Anesthesia and Critical Care, Livorno, Italy, 2 King’s College, Centre for Human Applied Physiological Sciences, School of Basic Medical Biosciences, London, UK, 3 Université Libre de Bruxelles ULB, Erasme Hospital, Department of Anesthesia and Critical Care, Brussels, Belgium

Critical Care 2026, 30 (Suppl 1): P047

Introduction: Conventional EIT impedance signals from ventilation alone cannot reliably distinguish between changes caused by lung collapse and those resulting from pleural cavity pathologies such as effusion or pneumothorax [1,2]. EIT-derived pulsatility signals reflecting cyclic changes in pulmonary perfusion, have emerged as a complementary marker of ventilation–perfusion matching. Because EIT pulsatility implies the presence of lung parenchyma, its integration with ventilation signals may help differentiate parenchymal from pleural processes and allow continuous monitoring of pleural cavity disease.

Methods: This ongoing prospective study included 7 patients so far with pleural cavity disease, 4 with hemothorax, 1 with reactive pleural effusion and 2 with pneumothorax. Continuous EIT analyses of ventilation and pulsatility-derived signals were obtained with ET 1000 (InfiVision)before and after treatment. Ultrasound images were used as the reference standard.

Results: Pleural disease manifested as an absence of both ventilation and pulsatility impedance signals in the affected regions and were confirmed in all patients (Figure). Following drainage of hemothorax and pleural effusion, pulsatility appeared without ventilation in 3 patients, indicating no re-expansion (i.e. atelectasis on US). Total re-expansion was observed in the other two patients. Pneumothorax was characterized by an absence of ventral perfusion pulsatility and ventilation signals and absence of sliding on chest ultrasound. Resolution of pneumothorax was associated with the reappearance of both ventilation and pulsatility signals.

Conclusions: This small case-series suggested that combining EIT ventilation and pulsatility signals may help discriminate between parenchymal and pleural pathology and allow continuous bedside monitoring. Notably, the presence or absence of pulsatility appears to be a key indicator of whether lung parenchyma is present even when ventilation is absent.

Figure (abstract P047) A) Absence of ventilation and pulsatility/perfusion impedance signal on left lung due to hemothorax (US image as reference), (B) Presence of pulsatility but no ventilation due to atelectasis after drainage (US image as reference). C) Absence of pulsatility and ventilation on left ventral region in pneumothorax and no sliding on US. D) Normal lung ventilation and pulsatility after drainage and presence of sliding on US

References Scaramuzzo G et al. Crit Care 2024;28:377 Ferro B et al. Intensive Care Med 2026;52:380-382

P048 Validation of patient-specific computational lung models using electrical impedance tomography in ARDS

M Rixner 1 , M Ludwig 2 , M Lindner 3 , I Frerichs 3 , A Sablewski 3 , KR Wichmann 1 , KW Müller 1 , D Schädler 3 , T Becher 3 , J Biehler 1

1 Ebenbuild GmbH, Ebenbuild GmbH, Munich, Germany, 2 Institute for Computational Mechanics, Technical University Munich, Munich, Bavaria, Germany, 3 Department of Anaesthesiology and Intensive Care Medicine, University Medical Center SchleswigHolstein Campus Kiel, Kiel, Germany

Critical Care 2026, 30 (Suppl 1): P048

Introduction: Personalizing ventilation settings in ARDS remains challenging due to complex regional pathophysiology and interindividual variability. Although electrical impedance tomography (EIT) can provide additional insight into regional ventilation, it offers limited spatial resolution and is subject to some practical limitations. We examine the potential of patient-specific, physics-based computational whole lung models to predict regional ventilation in mechanically ventilated patients, offering means of assessing lung mechanics.

Methods: For seven mechanically ventilated ARDS patients individualized computational lung models were constructed from CT scans and ventilatory waveform data. By resolving physical processes within the lung, the models predict regional airflow and parenchymal distension during mechanical ventilation. Model-predicted regional ventilation was quantitatively compared to EIT-derived measurements evaluating spatial agreement across multiple instances of the ventilation cycle.

Results: Model predictions demonstrated strong agreement with bedside EIT (Figure). Predicted anteroposterior ventilation distribution correlated closely with clinical data (R = 0.96) exceeding prior benchmarks established for EIT versus 4D-CT. This was maintained even when considering full spatial resolution across the transverse plane as well as full tidal ventilation range (R = 0.82, RMSE = 0.14) and despite the presence of marked pathological heterogeneity.

Conclusions: Our findings demonstrate that computational lung models can accurately predict regional ventilation phenomena within the lung. The findings demonstrate that patient-specific models can provide clinically relevant information, which could enable a novel way to further personalize and evaluate ventilator settings even before putting into application, based on both individual anatomy as well as pathophysiology.

Figure (abstract P048) Aggregate analysis of patient cohort for anteroposterior/lateral ventilation distribution

P049 Cardiac and lung ultrasound during a spontaneous breathing trial to predict extubation failure

CNL Groenland 1 , EJ Wils 2 , EA Dubois 1 , E Ter Bals 3 , TCD Rettig 4 , D Gommers 1 , L Heunks 5 , H Endeman 6 , VJM Baggen 1

1 Erasmus MC, Intensive Care Medicine, Rotterdam, Netherlands, 2 Franciscus Gasthuis Vlietland, Intensive Care Medicine, Rotterdam, Netherlands, 3 Groene Hart Ziekenhuis, Intensive Care Medicine, Gouda, Netherlands, 4 Amphia Ziekenhuis, Intensive Care Medicine, Breda, Netherlands, 5 Radboud University Medical Center, Intensive Care Medicine, Nijmegen, Netherlands, 6 OLVG, Intensive Care Medicine, Amsterdam, Netherlands

Critical Care 2026, 30 (Suppl 1): P0049

Introduction: Extubation failure occurs in up to 20%, despite a successful spontaneous breathing trial (SBT). Cardiac dysfunction and respiratory insufficiency are both potential causes of extubation failure. Ultrasound measurements during an SBT evaluating cardiac function and pulmonary oedema could identify patients at risk for extubation failure. We aimed to investigate the association between serial ultrasounds measurements during an SBT and extubation failure.

Methods: We included patients ventilated ≥ 48 h and undergoing an SBT followed by extubation in a multicenter cohort study. The primary endpoint was extubation failure (reintubation ≤ 7-days). Logistic regression was used to assess the associations of cardiac and lung ultrasound measurements at SBT start and the change (delta) during the SBT with extubation failure, adjusted for age and sex. Cardiac ultrasound measurements included systolic (left ventricular systolic dysfunction) and diastolic function (E/A ratio, e’ average, E/e’). Lung ultrasound (LUS) was performed according to the BLUE-protocol, with a maximum LUS score of 18 (maximum anterior LUS score of 12).

Results: We included 93 patients (mean age 62 ± 14 years, 61% male). Extubation failure occurred in 22%, of whom 76% experienced extubation failure due to respiratory or cardiac failure. Anterior LUS score was significantly higher in patients with extubation failure compared to success at start of the SBT (Table), with an adjusted OR of 1.71 (95% CI, 1.18 – 2.74). The change in anterior LUS score was not associated with extubation failure (OR 0.86, 95%CI, 0.50 – 1.36). Systolic and diastolic function parameters at start of the SBT and the change during the SBT were not significantly different.

Conclusions: Only the anterior LUS score at start of the SBT was associated with extubation failure; systolic and diastolic function parameters and their changes during the SBT were not. Lung ultrasound may provide incremental value in identifying patients at risk for extubation failure.

Table (abstract P049) Results

P050 MicroRNA–mRNA regulatory networks associated with oxygenation impairment in ARDS

Y Mitsuyama, H Matsumoto, T Ebihara, J Oda

The University of Osaka, Department of Traumatology and Acute Critical Medicine, Suita City, Japan

Critical Care 2026, 30 (Suppl 1): P050

Introduction: Acute respiratory distress syndrome (ARDS) involves complex inflammatory and metabolic dysregulation but coordinated regulation between mRNA and microRNA (miRNA) is not well defined. This study aimed to identify mRNA–miRNA co-expression networks in whole blood from ARDS patients and to determine modules and regulatory pairs associated with clinical severity.

Methods: Weighted gene co-expression network analysis (WGCNA) was applied to mRNA and miRNA expression profiles. Correlations between module eigengenes (MEs) and clinical parameters were examined. Hub genes were identified from the mRNA modules associated with clinical severity, and miRNA modules that were negatively correlated with these mRNA modules were used to extract hub miRNAs. Predicted target mRNAs from TargetScan were intersected with hub mRNAs to construct miRNA–mRNA pairs. Functional enrichment analyses were performed, and validated interactions were confirmed using miRTarBase.

Results: Thirty-four ARDS patients were analyzed; 47.1% had moderate ARDS, and hospital mortality was 8.8%. The mRNA ME1 module showed a significant negative correlation with the P/F ratio and was enriched for cytotoxic response, oxidative stress response, and gas transport. ME1 contained 379 hub genes. The miRNA ME2 module was negatively correlated with ME1 and included 20 hub miRNAs. Intersection analysis identified 102 predicted miRNA–mRNA pairs (72 unique genes), enriched in ubiquitin–proteasome system–related functions. miRTarBase confirmed 13 validated interactions, with miR-361-5p and miR-186-5p emerging as central regulators.

Conclusions: Integrative mRNA–miRNA analysis in ARDS revealed networks involving oxidative stress responses and the ubiquitin–proteasome system as contributors to oxygenation impairment. miR-361-5p and miR-186-5p represent potential upstream regulators and therapeutic targets in ARDS.

P051 MesenCure, a primed allogeneic cell therapy for ARDS: phase 2 COVID-19 study

V Kivity 1 , T Bronshtein 1 , A Novak 1 , D Ben David 1 , N Rozen 1 , S Meretzki 1 , T Hayek 2 , S Hamoud 2 , AF Shorr 3

1 Bonus Biogroup, Haifa, Israel, 2 Rambam Health Care Campus, Haifa, Israel, 3 MedStar Washington Hospital Center, Washington D.C., USA

Critical Care 2026, 30 (Suppl 1): P051

Introduction: Mesenchymal stem cell (MSC) therapies have not demonstrated consistent efficacy in ARDS, refocusing attention on next-generation products designed to achieve more robust effects. MesenCure is an ex vivo–primed allogeneic adipose-derived MSC therapy generated under conditions that enhance potency and stability, yielding distinct molecular profiles. We summarize outcomes from a phase 2 trial of MesenCure in COVID-19-related ARDS.

Methods: 50 patients (60% male) with severe COVID-19 pneumonia and hypoxemia received up to 3 IV MesenCure doses (1.5 × 10 6 cells/kg on days 1, 3, and 5) plus standard of care (SoC) and were compared with 150 contemporaneous controls who were propensity-matched for demographics, severity, and comorbidities. Median disease severity on WHO clinical progression scale was 6 (oxygen by non-invasive ventilation/high-flow) in the test group and 5 (oxygen by mask/nasal prongs) in the controls. The primary endpoint was safety; 28-day mortality, need for invasive mechanical ventilation (IMV), and hospital length of stay (LoS) were key additional endpoints.

Results: MesenCure was safe and associated with lower mortality (6.0% vs 18.7%; 68% relative reduction; p < 0.05) and lower progression to IMV (12.5% vs 29.3%; 57% relative reduction; p < 0.05) compared with controls, as well as a 38% (9.4-day) reduction in LoS among patients with LoS > 7 days ( p < 0.01). At the earlier of 2 weeks after the first MesenCure dose or hospital discharge, median CRP and CK levels were 52% ( p < 0.0001) and 33% ( p < 0.01) lower, respectively, in test patients vs. controls. These changes were accompanied by rapid resolution of pneumonia, improved respiratory function, and correction of lymphopenia.

Conclusions: MesenCure reduced mortality, morbidity, and key measures of inflammation and tissue damage in COVID-19-related ARDS. These clinically meaningful signals in viral ARDS support a US phase 3 trial designed to test whether a next-generation cell therapy can provide a disease-modifying option for all-cause ARDS.

P052 CEMIP-mediated hyaluronan fragmentation drives barrier disruption in acute respiratory distress syndrome

L Liu, S Chen, H Xue, D Hu, Y Zhu, Y Tang, A Liu, H Qiu, Y Yang, S Liu

Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China

Critical Care 2026, 30 (Suppl 1): P052

Introduction: Acute respiratory distress syndrome (ARDS) features disruption of the alveolar–capillary barrier, causing severe hypoxemia and high mortality. Hyaluronan (HA), a key extracellular matrix glycosaminoglycan, exists as high molecular weight HA (HHA) with barrier protective and anti inflammatory properties, and low molecular weight HA (LHA), which is pro inflammatory. We hypothesized that aberrant HA catabolism, particularly via cell migration–inducing hyaluronidase 1 (CEMIP), promotes ARDS progression.

Methods: Lipopolysaccharide (LPS) induced ARDS was established in mice receiving intratracheal HHA, LHA, or phosphate buffered saline. Lung injury was assessed by histopathology, edema indices, protein leakage, and cell death; tight junction proteins and inflammatory mediators were quantified. In vitro endothelial, epithelial, and macrophage injury, hyaluronan degrading enzyme expression, and CEMIP expressing bronchoalveolar lavage fluid populations were characterized.

Results: HHA alleviated lung histopathology, edema, protein leakage, and bronchoalveolar lavage fluid cell death and restored occludin and claudin 1 expression, whereas LHA aggravated injury and permeability. HHA reduced pulmonary inflammatory cytokine expression; LHA showed a pro inflammatory profile. In vitro, HHA limited cell injury, while LHA increased macrophage death. In ARDS lungs, hyaluronidase 1, hyaluronidase 2 and transmembrane protein 2 were downregulated, whereas CEMIP was markedly upregulated and strongly induced by LPS in epithelial cells and macrophages. Single cell data showed progressive enrichment of CEMIP positive alveolar macrophages and epithelial cells.

Conclusions: HHA and LHA exert opposing effects on lung barrier integrity and inflammation in ARDS. CEMIP is selectively upregulated and emerges as a key enzyme driving HHA degradation into pro inflammatory LHA, linking HA dysmetabolism to barrier failure. Targeting CEMIP mediated HA fragmentation may represent a promising therapeutic strategy in ARDS.

P053 S1P and 2,3-BPG in red blood cells during acute pneumonia: metabolic and functional adaptations

MS Winkler 1 , M Schmidt 1 , O Moerer 1 , PE Ziegler 2 , X Fedorov 2 , N Youssef 2 , S Blaschke 3 , U Olgemoeller 4 , B Tampe 5 , MH Gräler. 2

1 University Medical Center Göttingen, Department of Anesthesiology and Intensive Care Medicine, Göttingen, Germany, 2 Jena University Hospital, Department of Anesthesiology and Intensive Care Medicine, Center for Molecular Biomedicine CMB, Jena, Germany, 3 University Medical Center Göttingen, Emergency Department, Göttingen, Germany, 4 University Medical Center Göttingen, Department of Cardiology and Pneumology, Göttingen, Germany, 5 University Medical Center Göttingen, Department of Nephrology and Rheumatology, Göttingen, Germany

Critical Care 2026, 30 (Suppl 1): P053

Introduction: Pneumonia induces systemic inflammation and hypoxia. The bioactive lipid sphingosine-1-phosphate (S1P) has been linked to red blood cell (RBC) function and may facilitate oxygen unloading by stabilizing deoxygenated hemoglobin (Hb) [1,2]. We examined whether pneumonia triggers metabolic and functional RBC adaptations involving S1P, 2,3-bisphosphoglycerate (2,3-BPG), and Hb dynamics.

Methods: We analyzed RBC samples from ICU patients with pneumonia (n = 65) and 6 healthy controls. The study was approved by the ethics committee of the University Medical Center Göttingen (#14/11/21). S1P, ceramides, cholesterol, ATP, and 2,3-BPG were quantified using LC/MS, and mRNA expression of S1P-related genes and glycolytic enzymes assessed by qPCR. Hb oxygenation kinetics were measured spectrophotometrically (577 nm), and molecular interactions evaluated via Flow-Induced Dispersion Analysis (FIDA). Patient samples were analyzed on ICU days 1, 3, and 7 when available.

Results: Patients showed significantly reduced ceramide levels ( p < 0.001), elevated 2,3-BPG ( p < 0.0001), and increased ATP ( p < 0.0001). SPHK1/2 expression was upregulated ( p < 0.001), while SGPL1 was downregulated ( p < 0.05), indicating enhanced S1P synthesis. Hb oxygenation rate was significantly slower in patients ( p < 0.05), with a trend toward further reduction over time (days 1–7). FIDA data revealed altered hydrodynamic radii, supporting S1P-Hb interactions under hypoxic conditions.

Conclusions: Acute pneumonia triggers a metabolic shift toward S1P production and enhanced 2,3-BPG synthesis, promoting functional adaptation of hemoglobin to improve oxygen unloading. These changes evolve over time, supporting a protective role of S1P in hypoxic stress and highlighting its potential as a biomarker and therapeutic target in severe respiratory infections.

Acknowledgement: Funded by the German Research Foundation, DFG.

References Sun K et al. Nat Commun 2016;7:12086 Winkler MS et al. Clin Sci (Lond) 2021;135:2781–2791

P054 Exosomal miR-218 secreted from endothelial progenitor cells mitigates acute lung injury in sepsis mice by inhibiting HMGA1 in alveolar macrophages

GB Liang, ZH He

Third Xiangya Hospital, Department of Critical Care Medicine, Changsha, China

Critical Care 2026, 30 (Suppl 1): P054

Introduction: Sepsis-related acute lung injury (S-ALI) had become an important public health issue worldwide. However, the mechanism of S-ALI was still not fully understood. This study aims to investigate the possibility of exosomes secreted from endothelial progenitor cells (EPCs) serving as a carrier for microRNA (miR)-218 to alleviate S-ALI and explore the possible mechanism.

Methods: Exosomes were isolated from EPCs of C57BL/6J mice using differential centrifugation. Exosomes tracking in vivo and their uptake by EPCs in vitro were detected. miR-218 inhibitor and mimic were applied to investigate its function in mice and regulating polarization of alveolar macrophages (AMs). Bioinformatics and dual-luciferase reporter gene assays were used to explore the downstream targets of miR-218. si-HMGA1 and oe-HMGA1 were used to investigate its function in regulating polarization of AMs. Rescue experiments were carried out to uncover the interaction between miRNA-218 and HMGA1 in AMs.

Results: Exosomes were isolated from EPCs and confirmed their accumulation in the mice lung as well as their uptake by AMs in vitro. In vivo, miR-218 transferred by exosomes secreted from EPCs mitigated ALI. In vitro, miR-218 inhibitor enhanced LPS-induced polarization of M1 macrophages, while miR-218 mimic suppressed these reactions. HMGA1 was confirmed as a target gene of miR-218, and its over-expression offset the protective effects of miR-218.

Conclusions: miR-218 transferred by exosomes secreted from EPCs mitigated ALI in septic mice by inhibiting HMGA1 which regulates macrophages polarization (Figure).

Figure (abstract P054) Schematic

P055 Early neuromuscular blockade with or without dexamethasone in severe ARDS: A retrospective historical cohort study

M Benlabed 1 , S Benlabed 2 , R Gaudy 3 , A Benhamed 4 , R Mehyaoui 5 , J Malaska 6 , A Aberkane 7 , A Metali 5

1 Lille University, Anesthesiology and Intensive Care, Lille, France, 2 Free university of Brussels, Brussels, Belgium, 3 Lille University, Lille, France, 4 University of Oran, Oran, Algeria, 5 Algiers University, Algiers, 6 Masaryk University, Brno, Czech Republic, 7 University of Constantine, Constantine, Algeria

Critical Care 2026, 30 (Suppl 1): P055

Introduction: Early neuromuscular blocking agent (NMBA) [1] improves oxygenation in severe ARDS while dexamethasone reduces mortality and duration of mechanical ventilation (DEXA ARDS) [2]. After 2020, dexamethasone became standard of care. Prospective trials comparing NMBA alone versus NMBA + dexamethasone would likely be considered unethical. We performed a retrospective historical cohort study (2018–2024) to evaluate real-world outcomes.

Methods: We analyzed 400 adult ARDS patients:

• NMBA alone (pre-2020, n = 200): cisatracurium infusion for 48 h (Papazian protocol).

• NMBA + dexamethasone (post-2020, n = 200): cisatracurium + dexamethasone (10-day DEXA ARDS protocol).

Patients were matched using propensity scores for age, ARDS severity, comorbidities, PaO₂/FiO₂, and ventilatory settings. Continuous variables were compared using Mann–Whitney U test, and categorical variables using Chi-square or Fisher’s exact test. Primary endpoint: 90-day all-cause mortality. Secondary endpoints: 28-day mortality, ventilator-free days (VFD) at day 28, duration of mechanical ventilation, ICU-acquired weakness, PaO₂/FiO₂, and SOFA score.

Results:

• 28-day mortality: 38% vs 27% ( p < 0.02) (Figure).

• 90-day mortality: 40% vs 28% ( p < 0.01).

• VFD at day 28: 12 ± 6 vs 17 ± 5 days ( p < 0.001).

• Duration of mechanical ventilation: 18 ± 7 vs 13 ± 6 days ( p < 0.001).

• PaO₂/FiO₂ at day 7: 150 ± 45 vs 190 ± 50 mmHg ( p < 0.001).

• SOFA score at day 7: 10 ± 3 vs 8 ± 3 ( p < 0.01).

• NMBA + dexamethasone improved oxygenation compared with historical NMBA-alone cohorts.

Conclusions: Early dexamethasone added to 48-h NMBA was associated with lower 28- and 90-day mortality, more ventilator-free days, shorter duration of mechanical ventilation, and improved PaO₂/FiO₂ and SOFA scores compared with matched historical NMBA-alone patients. These results highlight the real-world benefit of combining NMBA and corticosteroids in severe ARDS and confirm that prospective trials withholding dexamethasone would now be unethical.

References Papazian L et al. N Engl J Med 2010;363:1107–16 Villar J et al. Lancet Respir Med 2020;8:267–276

Figure (abstract P055) Mortality according to therapeutic strategy: comparison of early NMBA (historical cohort, pre-2020) versus early NMBA + dexamethasone (post -2020 cohort)

P056 Comparison of fixed versus individualized positive end-expiratory pressure strategies in a unilateral porcine “triple-hit” acute lung injury model

S Böhmann 1 , B Seybold 1 , CH Mutschler 1 , A Wulfinghoff 1 , J Schenz 1 , N Englert 2 , D Cetiner 3 , T Poth 4 , MA Weigand 1 , MO Fiedler Kalenka 1

1 Heidelberg University Hospital, Medical Faculty, Department of Anesthesiology, Heidelberg, Germany, 2 Heidelberg University Hospital, Medical Faculty, Department of Pathology, Heidelberg, Germany, 3 Heidelberg University Hospital, Medical Faculty, Department of Diagnostic and Interventional Radiology, Heidelberg, Germany, 4 Heidelberg University Hospital, Medical Faculty, Center for Model System and Comparative Pathology CMCP, Heidelberg, Germany

Critical Care 2026, 30 (Suppl 1): P056

Introduction: Acute lung injury (ALI) involves heterogeneous lung damage and loss of functional lung tissue [1]. During invasive ventilation, individualized positive end-expiratory pressure (PEEP) titration aims to optimize tidal volume distribution and minimize further lung injury through atelectrauma and volutrauma.

Methods: Unilateral lung injury was induced in 10 anesthetized pigs by left lung inhalation (0.33 mg/kg) and direct intrapulmonary arterial injection (0.24 mg/kg) of lipopolysaccharide (LPS), combined with 1 h left pulmonary artery occlusion. Animals were randomized to either fixed PEEP (Group A, 5 cmH2O, n = 6) or individualized PEEP (Group B, titrated based on transpulmonary pressure (TPP) via esophageal pressure monitoring [2], n = 4). Mechanical ventilation was maintained for 6 h with hourly recording of respiratory and hemodynamic parameters. Finally, tissue, serum and bronchoalveolar lavage samples were collected and chest CT scan was performed.

Results: As illustrated in the Figure, values are presented as median and interquartile range (IQR). After 6 h, the TPP guided strategy in Group B was associated with higher oxygenation (P/F 229.75 [140.13] vs. 139.64 [146.76] mmHg) and higher compliance (24.0 [5.0] vs. 20.50 [8.0] ml/cmH 2 O), with a tendency towards lower driving pressure (∆P) (12.40 [2.20] vs. 13.55 [5.60] cmH 2 O). Mechanical power was higher in Group B (18.15 [2.49] vs. 14.65 [2.0] J/min) and PEEP levels differed markedly between groups (10.50 [3.0] vs. 5.0 [0.0] cmH 2 O).

Conclusions: These preliminary data suggest that individualized TPP guided PEEP may improve gas exchange and lung mechanics. Further experiments are required to determine whether the observed increase in mechanical power merely reflects higher static strain or contributes to additional tissue damage. Effects on imaging and translational relevance remain to be examined.

References Meyer NJ et al. Lancet 2021;398:622-37 Mauri T et al. Intensive Care Med 2016;42:1360-73

Figure (abstract P056) Median and IQR for (1) P/F ratio [mmHg], (2) Compliance [ml/cmH 2 O], (3) Driving pressure [cmH 2 O], (4) Mechanical power [J/min] after 6 h of ventilation

P057 Comparative effectiveness of individual lung ventilation strategies to PEEP titration in ARDS patients: a systematic review and network meta-analysis

F Mingxing 1 , R Hanchen 2

1 Hebei Medical University Third Hospital, Intensive Care Unit, China, 2 Hebei Medical University Third Hospital, China

Critical Care 2026, 30 (Suppl 1): P057

Introduction: This network meta-analysis aimed to compare the efficacy of individualized positive end-expiratory pressure (PEEP) titration strategies for reducing mortality and improving outcomes in patients with acute respiratory distress syndrome (ARDS).

Methods: The study protocol was registered on PROSPERO (CRD420251041273). A comprehensive search was conducted in PubMed, Web of Science, Embase, the Cochrane Library, CNKI, and Wanfang Data up to October 21, 2024, including randomized controlled trials of mechanically ventilated ARDS patients. Network meta-analysis was performed using R software. Evaluated PEEP titration strategies included transpulmonary pressure, driving pressure, optimal compliance, pressure–volume curve, electrical impedance tomography, ultrasound, and conventional methods (predominantly ARDSnet protocol). Primary outcome was 28-day mortality; secondary outcomes included oxygenation index, ICU length of stay, and duration of mechanical ventilation.

Results: Twenty-six RCTs involving 3400 critically ill patients were included. Seventeen studies reported 28-day mortality, 16 reported oxygenation index, 12 reported ICU length of stay, and 8 reported duration of mechanical ventilation. Compared with conventional methods, the transpulmonary pressure-guided strategy significantly reduced 28-day mortality (HR: 0.56, 95% CI: 0.32–0.92) and improved oxygenation (MD: 50.95, 95% CI: 16.09–86.14) (Figure). Surface under the cumulative ranking curve (SUCRA) analysis showed the driving pressure-guided strategy may be superior in shortening mechanical ventilation duration (89%) and ICU length of stay (92%), though these differences lacked statistical significance.

Conclusions: Transpulmonary pressure-guided PEEP titration is superior to conventional methods in reducing 28-day mortality and improving oxygenation in ARDS patients. The driving pressure-guided strategy may be preferable for reducing the duration of mechanical ventilation and ICU stay, but this finding requires validation in future clinical trials.

Figure (abstract P057) Outcomes. Upper panel: Data in the lower-left cell correspond to the primary study endpoint 28-day mortality, while data in the upper-right cell correspond to length of hospital stay. Lower panel: Data correspond to duration of mechanical ventilation (lower-left half) and oxygenation index (upper-right half)

P059 Development and validation of a dynamic prediction model for treatment failure in patients undergoing awake prone positioning

Y Li, L Liu

School of Medicine, Zhongda Hospital, Southeast University, Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Nanjing, China

Critical Care 2026, 30 (Suppl 1): P059

Introduction: Acute hypoxemic respiratory failure (AHRF) is common in ICU. Awake prone positioning (APP) improves oxygenation and reduces intubation [1]. 40% still require intubation or die (APP failure), increasing mortality. We developed and validated a dynamic model to quantify APP-failure risk and support early intubation.

Methods: Data from a multicenter RCT split 1:1 into development and validation cohorts [2]. We collected baseline clinical and laboratory data, plus daily post-APP measures (SpO 2 /FiO 2 , heart rate, respiratory support). A joint model generated dynamic predictions; performance was assessed by AUC and calibration plots. Patients were stratified into high and low-risk groups by the optimal cutoff, and APP failure rates were compared by log-rank.

Results: 404 patients were randomized 1:1 (202/202). HFOT at admission, white blood cell count, total bilirubin, and GCS independently predicted APP failure. Linear mixed models showed rising SpO₂/FiO₂, falling heart rate, and step-down respiratory support during APP; joint modeling integrated these with survival data to form the dynamic model. AUC increased from day 1–7: development: 0.854 (0.784–0.924) → 0.946 (0.903–0.988); validation: 0.762 (0.690–0.833) → 0.883 (0.803–0.963). Calibration was near-ideal. The optimal cutoff (Youden) was 0.136, separating high and low-risk groups with significantly different failure rates.

Conclusions: The dynamic model provides time-updated risk estimates with strong discrimination and calibration; its performance improves over time and accurately predicts APP failure.

References Ehrmann S et al. Lancet Respir Med 2021;9:1387-1395 Liu L et al. Intensive Care Med 2024;50:1298-1309

P061 Hemodynamic effects of prone position on patients with moderate to severe ARDS and varying lung recruitability: a physiological observational study

S Yang 1 , T Liu 1 , M Yan 1 , Y Li 1 , J Xu 1 , J Xie 1 , F Guo 1 , C Pan 2

1 Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China, 2 Department of Intensive Care Medicine, Sichuan Academy of Medical Sciences Sichuan Provincial People’s Hospital Affiliated Hospital of University of Electronic Science and Technology of China, Chengdu, China

Critical Care 2026, 30 (Suppl 1): P061

Introduction: Prone positioning (PP) is a key therapeutic intervention for ARDS. Lung recruitability represents an extrinsic phenotype of ARDS, but the hemodynamic response to PP in ARDS with varying lung recruitability remains unclear.

Methods: This prospective observational study was carried out at a comprehensive ICU. ARDS Patients receiving invasive ventilation were stratified by recruitability and its pre/post-PP changes(ΔR/I ratio). Echocardiogram was conducted at SP and Re-SP. Respiratory mechanics, ABG and EIT were utilized at SP, PP3H, PP12H and Re-SP.

Results: Were stratified into two subgroups based on baseline lung recruitability: 9 patients (60.0%) had low-recruitability ARDS, and 6 patients (40.0%) had high-recruitability ARDS. Additionally, the entire cohort was further divided into two groups according to the ΔR/I ratio: 8 patients (53.3%) were classified as small-ΔR/I ARDS, and 7 patients (46.7%) as large-ΔR/I ARDS. In the overall cohort, PP significantly decreased PASP (44.60 [37.35, 54.40] vs. 37.40 [30.50, 43.75] mmHg; p = 0.024) and increased Tapse/PASP( 0.44 [0.38, 0.56] vs. 0.57 [0.48, 0.71] mm/mmHg; p = 0.026). However, despite the favorable respiratory physiological effects induced by PP, no significant reductions in PASP or improvements in Tapse/PASP were observed in the subgroups stratified by baseline lung recruitability. Notably, in the large-ΔR/I ARDS group, PP resulted in a significant reduction in PASP (51.00 [43.00, 54.10] vs. 38.00 [36.65, 40.40] mmHg; p = 0.026). In contrast, no such significant effect of PP on PASP was detected in the small-ΔR/I ARDS group.

Conclusions: Regarding the hemodynamic effects of PP in moderate to severe ARDS, the dynamic change characteristic of lung recruitability exerts a greater impact on hemodynamic parameters than lung recruitability per se. Only in large-ΔR/I ARDS, PASP decreased significantly after PP.

P062 The effect of prone positioning application for over and under 24 h on gas exchange in COVID-19 ARDS (acute respiratory distress syndrome) patients

A Atli 1 , O Kayhan 2 , O Demirkiran 2

1 Cerrahpaşa Faculty of Medicine, Department of Anesthesiology and Reanimation, Istanbul, Turkey, 2 Cerrahpaşa Faculty of Medicine, Istanbul, Turkey

Critical Care 2026, 30 (Suppl 1): P062

Introduction: The main purpose of the study is to determine the difference in effectiveness of shortterm (16–24 h) and long-term (24–36 h) prone positioning on gas exchange (oxygenation and carbon dioxide elimination) in COVID-19 ARDS patients, and consequently, to reduce complications and care difficulty by determining the most optimal application duration.

Methods: Patients who were hospitalized in a university hospital intensive care unit from the beginning of the pandemic until the end of 2021, diagnosed with severe ARDS according to the Berlin criteria, and underwent invasive mechanical ventilation were included in the study. Patients were divided into two groups according to prone duration: Short Prone (16–24 h, n = 41) and Long Prone (24–36 h, n = 38). Arterial blood gas (ABG) and mechanical ventilation data (PEEP, PaCO 2 , PaO 2 /FiO 2 ) were recorded just before prone, during the first and last hours of prone position, and after returning to the supine position.

Results: Prone positioning improves oxygenation and increases carbon dioxide elimination in COVID-19 ARDS patients in the short term. Extending the prone position beyond 24 h provides no additional benefit. A significant decrease in PaO 2 /FiO 2 ratios was observed upon returning to the supine position. The carbon dioxide level, which was similar at the beginning, differed significantly in favor of women at the end of prone and afterwards. The effects of the prone position were found to be more limited and rapidly reversible in male patients. The more pronounced drop in PaO 2 /FiO 2 after returning to supine in men suggests that males have a weaker response to the prone position and their oxygenation parameters deteriorate faster.

Conclusions: In light of the data obtained from the study, it was generally observed that long-term (> 24 h) prone positioning was not significant for patients in terms of respiratory. These findings emphasize the need for individualizing treatment strategies and considering gender differences.

P063 ROX index in the prone position as a predictor of successful high-flow nasal cannula therapy in COVID-19-associated acute respiratory failure: a single-center retrospective study

Y Kato 1 , K Tamai 2 , H Takahashi 2

1 Okayama Kyokuto Hospital, Department of Emergency Medicine, Okayama, Japan, 2 Saiseikai Yokohamashi Tobu Hospital, Department of Intensive Care Medicine, Yokohama Kanagawa, Japan

Critical Care 2026, 30 (Suppl 1): P063

Introduction: The ROX index, which is the ratio of the oxygen saturation to the fraction of inspired oxygen and respiratory rate (SpO 2 / FiO 2 / RR), can predict the success of high-flow nasal cannula (HFNC) therapy. Although some studies have revealed its applicability in patients with Coronavirus disease 2019 (COVID-19), its utility during prone positioning therapy has not been validated. Therefore, we aimed to determine whether the ROX index in the prone position could predict the success of HFNC therapy.

Methods: This retrospective observational study included patients with COVID-19 who underwent HFNC and awake-prone positioning therapy. The ROX index in both the supine and prone positions was calculated at < 12 h and 12–24 h after starting HFNC therapy, and once daily thereafter until HFNC termination. HFNC failure was defined as need for mechanical ventilation (MV) or death.

Results: Of the 69 patients included, 61 (88.4%) were weaned off HFNC, whereas HFNC therapy failed in eight patients. Of the eight patients with HNFC failure, four switched to MV and four died during HFNC therapy. In the HFNC success group, the ROX indices were significantly higher values in the prone position than in the supine position. However, this difference was not observed in the HFNC failure group. In the receiver operating characteristic analysis, the best predictor for HFNC success was the ROX index at < 12 h in the prone position (Area under the curve (AUC), 0.906), and the threshold of 7.71 had a sensitivity of 88% and specificity of 88%, whereas in the supine position AUC was 0.747 and the threshold of 5.47 had sensitivity of 87% and specificity of 50%. In the multivariate logistic regression analysis, the ROX index in the prone position at < 12 h showed good predictive value for HFNC success (OR, 3.786; 95% CI, 1.264–11.337; p = 0.017).

Conclusions : The ROX index in the prone position has good predictive capacity for HFNC success and can be useful for the optimal selection of patients for HFNC therapy.

P065 Effect of prone positioning on pathophysiology and lung histopathology during VV-ECMO in severe ARDS: an experimental animal study

E Barbeta 1 , L Zattera 1 , K Kiarostami 2 , R Cabrera 2 , L FernándezBarat 2 , A Motos 2 , J Riera 3 , C Ferrando 1 , A Torres 4

1 Hospital Clinic de Barcelona, ICU, Barcelona, Spain, 2 University of Barcelona, IDIBAPS, Barcelona, Spain, 3 Hospital Vall d´Hebró, ICU, Barcelona, Spain, 4 University of Barcelona, ICU, Barcelona, Spain

Critical Care 2026, 30 (Suppl 1): P065

Introduction: Prone positioning improves survival in patients with acute respiratory distress syndrome (ARDS), primarily by reducing ventilator-induced lung injury. Whether these physiological benefits translate to patients supported with veno-venous extracorporeal membrane oxygenation (VV-ECMO) remains uncertain.

Methods: Pigs with severe ARDS were placed on VV-ECMO and randomized to either prone or supine positioning (48h) under an ultraprotective ventilation strategy. Futility analyses were performed at half of the planned sample size using conditional power calculations, with early termination criteria set at < 10% probability of achieving statistical significance. We aimed to compare the effects of prone versus supine positions on the wet-to-dry lung weight ratio, gas exchange, respiratory mechanics, electrical impedance tomography, histopathology, microbiology, hemodynamics, and extracorporeal circuit function in pigs with severe ARDS undergoing VV-ECMO.

Results: Eight pigs with severe ARDS were randomized after VV-ECMO initiation. Prone positioning, compared with the supine, resulted in a similar wet-to-dry lung weight ratio (6.77 [6.13–8.17] vs. 6.70 [6.22–8.48]; p = 0.89), meeting the futility threshold. In the prone group, non-dependent areas accounted for 51 [47–61.3]% of total ventilation compared to 86 [68.5–90]% in the supine ( p = 0.02). Prone positioning redistributed histopathological lung injury, with relative preservation of non-dependent areas and greater damage in dependent zones, but without a net global decrease (Figure).

Conclusions: Prone positioning did not decrease the overall severity of lung injury. Rather, it shifted the distribution of damage, with greater involvement of dependent regions and relative preservation of non-dependent areas.

Figure (abstract P065) Results

P066 Safety and performance of the Novalung ultimate kit and the Xenios 2.0 during stationary use in hospital and ground-based transport of patients on extracorporeal life support (ECLS)

F Bellando 1 , A Derlet Savoia 2 , F Bitsch 3 , U Feiler 3 , T Rinne 3

1 Fresenius Medical Care Deutschland GmbH, Clinical Research, Bad Homburg, Germany, 2 Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany, 3 Xenios AG, Heilbronn, Germany

Critical Care 2026, 30 (Suppl 1): P066

Introduction: With the growing number of ECMO indications and the specialization of ECMO centers, the transfer of patients from remote hospitals to tertiary care facilities has become a crucial element for successful treatment. The aim of this study is to evaluate the performance and safety of the Xenios system (Novalung ultimate kit, Xenios 2.0, MultiSupport Ground (Xenios AG)) in patients transported and treated stationary on ECMO. It will be evaluated whether the combined use of the medical devices can improve and maintain the gas exchange and cardiocirculation in these patients.

Methods: This is a prospective, multi-centre, observational post-market clinical follow-up study. 20 patients with severe acute respiratory and/or cardiopulmonary failure in need of VV or VA ECMO will be allocated in two equal sub-groups, depending on whether they receive an inter-hospital transport and stationary ECMO treatment or a stationary ECMO treatment only. Participating patients will be treated according to local clinical practice. Data will be recorded before ECMO initiation (Baseline), after ECMO initiation, during ground-based transport, and every 24 h until ECMO discontinuation. The primary analysis will be conducted in the full sample. The change in arterial oxygen saturation (SaO 2 ) from pre-ECMO initiation to 24 h after ECMO initiation is evaluated as the primary endpoint. Secondary endpoints include, among others, cardiocirculatory improvement, ventilatory settings and respective gas exchange in the patient, safety and performance of the Xenios system, and patient outcomes.

Results: The clinical phase will start in Q1 2026. The overall recruitment phase will be limited to 12 months. The final study results are planned to be published in 2027.

Conclusions: This study aims to demonstrate the safety and efficacy of the Xenios system and is expected to provide valuable evidence to support its clinical use in adult patients with an ECMO indication during ground-based transport and stationary use.

P067 Reevaluation of oxygenation targets in patients with acute respiratory failure and veno-venous extracorporeal membrane oxygenation

V Bünger 1 , M Ruß 1 , L La Via 2 , WM Kübler 3 , S WeberCarstens 1 , JA Graw 4

1 Charité Universitätsmedizin Berlin, Anesthesiology and Intensive Care Medicine, Berlin, Germany, 2 University of Catania, General Surgery and Medical Surgical Specialties, Catania, Italy, 3 Charité Universitätsmedizin Berlin, Physiology, Berlin, Germany, 4 University of ErlangenNuremberg FAU, Anesthesia and Intensive Care Medicine, Erlangen, Germany

Critical Care 2026, 30 (Suppl 1): P067

Introduction: Many patients in the intensive care unit (ICU) receive high fractions of inhaled oxygen (FiO 2 ) to secure blood oxygenation and tissue supply with oxygen. However, there is increasing evidence that exposure to high FiO 2 is associated with adverse effects. In patients with a severe acute respiratory distress syndrome (ARDS) and refractory hypoxemic respiratory failure, veno-venous extracorporeal membrane oxygenation (VV-ECMO) can be implemented as a rescue therapy. Target levels for partial pressure of oxygen in arterial blood (PaO 2 ) can be controlled by the VV-ECMO. So far, optimal oxygenation targets in patients with ARDS treated with VV-ECMO are unknown.

Methods: Retrospective analysis of 443 patients with severe ARDS and treatment with VV-ECMO. Regression analyses were performed for mortality and time-weighted averages of PaO 2 and FiO 2 . Furthermore, considering a possible non-linear relationship, a restricted cubic spline (RCS) model was performed for PaO 2 .

Results: A simple logistic regression for mean PaO 2 and ICU mortality showed a significant positive association (per mmHg OR 0.99 [95%CI 0.98–1.00], p = 0.002). RCS analysis showed a U-shaped association of mortality and mean PaO 2 (PaO 2 69.70–90.24 mmHg: OR 0.92 [95%CI 0.89–0.94], p < 0.001; PaO 2 90.24–123.40 mmHg: 1.09 [1.06–1.13], p < 0.001). A model including PaO 2 as restricted cubic spline variable and FiO 2 showed significant associations of mortality with both variables (PaO 2 69.70–90.24 mmHg: OR 0.94 [0.91–0.97], p < 0.001, paO 2 90.24–123.40 mmHg: OR 1.07 [1.04–1.11], p < 0.001, FiO 2 : OR 33.48 [8.01–148.43], p < 0.001, VIF < 1.15).

Conclusions: The results of this observational study suggest that PaO 2 -values below 90 and above 123 mmHg both are associated with an increased mortality in patients with ARDS and treatment with VV-ECMO.

P068 Retrospective analysis of peripheral neuropathy in patients recovering from veno-arterial and veno-venous ECMO support

VD Dupon 1 , CR Redant 2 , HP Peperstraete 1

1 Ghent University Hospital, Intensive Care Medicine, Ghent, Belgium, 2 Ghent University Hospital, Physical and Rehabilitation Medicine, Ghent, Belgium

Critical Care 2026, 30 (Suppl 1): P068

Introduction: Extracorporeal membrane oxygenation (ECMO) is a potential life-saving therapy in critically ill patients suffering from cardiac arrest, acute cardiac or pulmonary failure [1]. Many of these patients suffer from critical illness weakness (CIW), defined by a Medical Research Council (MRC) sum score below 48. A less described complication of ECMO support is peripheral neuropathy (PN), impacting the patient’s recovery and quality of life [2]. The aim of this study was to explore the prevalence and associated factors of PN in ECMO survivors.

Methods: This retrospective cohort study included adult patients who survived at least 6 months after VA or VV ECMO support in the Ghent University Hospital (Belgium) from 2016 to 2024.

Results: The 6-months survival rate was 42.5% or 107 of 251 patients. Relevant patient demographics and clinical characteristics are shown in the Table. The overall incidence of CIW was 73.8% (n = 79). Among these patients, 35.4% (n = 28) underwent EMG examination. PN (on the side of one of the ECMO cannulas) occurred in 12 patients (11.2%), including 7 on VA-ECMO and 5 on VV-ECMO. The peroneal nerve was most frequently affected, followed by the brachial plexus and femoral nerve. Neuropathy was predominantly motor (n = 7), with 6 patients presenting foot drop. Due to the low number of neuropathy events, multivariable logistic regression was not feasible. In univariable testing, continuous administration of neuromuscular blocking drugs (NMBD) and presence of CIW based upon the MRC sum score were significantly associated with an increased risk of PN ( p = 0.018 and p = 0.034).

Conclusions: Continuous use of NMBD and presence of CIW are significant risk factors for development of PN in patients requiring ECMO support. EMG screening may be beneficial for timely detection, leading to less underdiagnosing of PN.

References Burell A et al. Cochrane Database Syst Rev 2023;9:CD010381 Johannes F et al. J Intensive Care Med 2024;39:534-541

Table (abstract P068) Relevant patient demographics and clinical characteristics

P069 Physiological response to ECMO as a rescue strategy in near-fatal asthma: five-case series from two Spanish intensive care units

E Marcano Millán 1 , M San Martín Bragado 2 , F Martín González 3 , M Gallardosantos 2 , E Pérez Losada 3 , L Roldán Furelos 2 , S Muñoz González 3 , J Figueroa Falconi 3 , J Granados Ricaurte 3 , V Sagredo Meneses 3

1 Hospital Universitario de Salamanca, Critical Care Unit, Salamanca, Spain, 2 Hospital Universitario Doctor Negrín, Las Palmas, Spain, 3 Hospital Universitario de Salamanca, Salamanca, Spain

Critical Care 2026, 30 (Suppl 1): P069

Introduction: Near-fatal asthma is a life-threatening respiratory emergency where extreme hypercapnia and acidosis may become refractory to conventional ventilation. Extracorporeal membrane oxygenation (ECMO) has emerged as an effective rescue option in such situations.

Methods: A retrospective descriptive study was conducted in the intensive care units (ICUs) of the University Hospital of Salamanca and the University Hospital Dr. Negrín, Spain. Five patients with severe status asthmaticus requiring ECMO between 2019 and 2025 were analyzed. Demographic, clinical, ventilatory, and blood gas data, as well as ECMO characteristics and outcomes, were collected and expressed as medians and interquartile ranges (IQR).

Results: Median [Me] age was 45 years [IQR: 7]; 60% (3/5) were male. Me weight, body mass index (BMI), and height were 85 kg [IQR: 10], 27.4 [IQR: 4.8], and 178 cm [IQR: 5], respectively. All cases had an infectious trigger. Pre-ECMO values showed severe respiratory acidosis with pH 7.09 [IQR: 0.18] and PaCO₂ 115 mmHg [IQR: 14] (Figure). Four patients received veno-venous ECMO and one veno-arteriovenous ECMO. Time to cannulation was 8 h [IQR: 3–10], and ECMO duration was 144 h [IQR: 139–168]. Protective ventilation was achieved with a reduction in driving pressure from 20 to 14 cmH₂O and in peak inspiratory pressure (PIP) from 34 to 25 cmH₂O. All patients received inhaled bronchodilators and ketamine as a bronchodilator-sedative; 60% received intravenous salbutamol, one case used Heliox® 70/30, and one received early benralizumab. All presented hypophosphoremia (Me 1.9 mg/dL; ref. 2.5–4.5). Two patients developed non-fatal bleeding, none required dialysis, and one died from anoxic encephalopathy with intracranial hemorrhage.

Conclusions: This multicentre Spanish series highlights ECMO as an effective rescue therapy for NFA, allowing safe gas exchange and lung-protective ventilation with an acceptable complication profile. Larger registries are needed to better define patient selection and management strategies.

Figure (abstract P069) Physiologic and ventilatory response to ECMO in five patients with near-fatal asthma

P070 A UK single centre retrospective cohort study describing hypertriglyceridemia management in patients on venovenous-extracorporeal membrane oxygenation (VV-ECMO): Fenofibrate versus standard care

V Milic, M Adesuyan, F Hanks, P Sherren

Guys and St Thomas NHS Foundation Trust, London, UK

Critical Care 2026, 30 (Suppl 1): P070

Introduction: Significant hypertriglyceridemia in patients receiving VV-ECMO has been associated with impaired extracorporeal membrane efficiency and possibly failure. Given the potential clinical complications and financial implications associated with circuit change, strategies to mitigate triglyceride (TG) elevation are important. Since 2017, our ECMO centre has incorporated fenofibrate as adjunctive therapy to manage rising triglyceride levels. The aim of this retrospective cohort study was to evaluate whether the introduction of fenofibrate was associated with changes in TG levels among our VV-ECMO population.

Methods: Using electronic health records from a UK tertiary referral centre, we compared VV-ECMO patients across a 5 year period with TG ≥ 5.64 mmol/L who were managed across a six day period with and without fenofibrate 160mg daily. We conducted a descriptive analysis of baseline characteristics and fitted a linear mixed-effects model to estimate triglyceride changes in each group.

Results: 23 patients were identified (fenofibrate n = 10; non-fenofibrate n = 13) and baseline TG levels were similar: fenofibrate group (median 7.57 mmol/L [IQR 7.00–9.56]) compared with non-users (6.43 mmol/L [IQR 6.06–6.77]; p = 0.08). The fenofibrate group showed a greater reduction in TG (median − 3.88 mmol/L [IQR − 4.54 to − 2.49]) compared with non-users (− 2.20 mmol/L [IQR − 3.13 to − 1.05]; p = 0.056) (Figure). Cumulative propofol exposure was comparable between groups whereas cumulative midazolam exposure was significantly greater in the fenofibrate group (median 886.5 mg [IQR 511–1704]) compared with non-users (50 mg [IQR 0–747]; p = 0.03).

Conclusions: Fenofibrate use was associated with a greater reduction in serum TG over six days. While these findings are limited by sample size and confounders, they highlight the possible role of fenofibrate in managing hypertriglyceridemia during VV-ECMO. Larger controlled studies are needed to investigate efficacy and safety of fenofibrate and the influence on ECMO circuit lifespan.

Figure (abstract P070) Unadjusted linear mixed-effects model showing predicted triglyceride levels over time in fenofibrate users vs non-users

P071 Comparison of different positive end-expiratory pressure strategies in a unilateral porcine acute lung injury model with early venovenous extracorporeal membrane oxygenation support

A Wulfinghoff 1 , B Seybold 1 , CH Mutschler 1 , N Englert 2 , D Cetiner 3 , L Wucherpfennig 3 , T Poth 4 , MA Weigand 1 , A Kalenka 1 , MO Fiedler Kalenka 1

1 Heidelberg University Hospital, Department of Anesthesiology, Heidelberg, Germany, 2 Heidelberg University Hospital, Department of Pathology, Heidelberg, Germany, 3 Heidelberg University Hospital, Department of Diagnostic and Interventional Radiology, Heidelberg, Germany, 4 Heidelberg University Hospital, Center for Model System and Comparative Pathology CMCP, Heidelberg, Germany

Critical Care 2026, 30 (Suppl 1): P071

Introduction: Lung-protective ventilation is the standard of care for acute respiratory failure, aiming to reduce ventilator-induced lung injury [1,2]. Venovenous extracorporeal membrane oxygenation (vv-ECMO) provides a therapeutic option during respiratory failure to further reduce mechanical power (MP). However, the optimal positive end-expiratory pressure (PEEP) strategy remains unclear.

Methods: Left-sided acute lung injury (ALI) was induced by saline/Triton X-100 lavage. Vv-ECMO was initiated to allow de-escalation of mechanical ventilation. Animals (n = 8) were randomized (4:4) and ventilated in airway pressure release ventilation mode (Inspiratory pressure (Phigh): PEEP + 10 cmH₂O, respiratory rate 5, FiO₂ 0.4). PEEP was set to 0 cmH₂O (Group A) or titrated (Group B), targeting slightly positive end-expiratory transpulmonary pressure (TPPexp) using an esophageal catheter. Respiratory and hemodynamic parameters were recorded over 8 h. Lung tissue and serum samples were collected and a chest computed tomography (CT) scan was performed.

Results: PEEP values were markedly higher in Group B (11.5 [3] vs. 0 [0] cmH₂O) (Figure). The resulting TPPexp differed clearly between groups (A = -3.85 [3.28], B = 1.15 [2.15] cmH₂O). After 8 h, MP, compliance, and driving pressure (ΔP) were comparable in Group A vs. Group B (MP: 0.67 [0.41] vs. 1.3 [0.6] J/min; compliance: 22 [10] vs. 17.5 [14] mL/cmH₂O; ΔP: 8.0 [0.4] vs. 8.5 [2.2] cmH₂O). Using a modified Ichikado scoring system, CT imaging showed a notably higher score in the left lung vs. right lung (320 [61.7] vs. 183.3 [90]), confirming successful unilateral implementation of the ALI model. A slight increase in left-lung injury scores was observed in Group A (341.7 [100] vs. 325 [67.5]).

Conclusions: The applied PEEP strategies showed no marked differences in MP, compliance or ΔP. CT-derived injury scores implied a slight advantage for Group B. Effects on tissue and translational relevance remain to be examined.

References Tasaka S et al. J Intensive Care 2022;10:32 Bellani G et al. JAMA 2016;315:788-800

Figure (abstract P071) Median and interquartile range (IQR) in Group A vs. Group B for (1) Compliance [mL/cmH₂O], (2) Driving pressure [cmH₂O], (3) Mechanical Power [J/min], (4) Pplateau [cmH 2 O], (5) End-expiratory transpulmonary pressure (TPPexp) [cmH₂O], (6) positive end-expiratory (PEEP) [cmH₂O]

P072 High vasoactive-inotropic score deteriorates outcomes of septic patients receiving veno-venous extracorporeal membrane oxygenation support: a retrospective cohort study from CSECLS registry database

Y Xie, X Hou, H Wang

Beijing Anzhen Hospital, Capital Medical University, Center for Cardiac Intensive Care, Beijing, China

Critical Care 2026, 30 (Suppl 1): P072

Introduction: This study aimed to examine the association between high vasoactive-inotropic score (VIS) and outcomes in patients with sepsis receiving veno-venous (V-V) extracorporeal membrane oxygenation (ECMO) support.

Methods: Clinical data were retrospectively analyzed from the Chinese Society of ExtraCorporeal Life Support registry database between January 2017 and June 2023. A total of 274 adult patients with sepsis who received V-V ECMO were included. Based on a VIS threshold of 60, participants were categorized into high VIS and non-high VIS groups, according to their VIS at 24 h after ECMO initiation. In-hospital mortality, ECMO configuration conversion, and complications were compared between groups.

Results: Among the 274 participants, the overall in-hospital mortality rate was 49.3%. The high VIS group had a significantly higher mortality rate than the non-high VIS group (59.8% vs. 44.8%, p = 0.023) (Figure). Bleeding complications (24.3% vs. 13.5%), hyperbilirubinemia (31.7% vs. 13.6%), and need for continuous renal replacement therapy (64.6% vs. 47.9%) were also more frequent in the high VIS group. Fifteen patients initially supported with V–V ECMO later required conversion to V–A ECMO or V–A–V ECMO, with a mortality rate of 66.6%. No significant differences in adjuvant configuration conversions were observed between VIS groups.

Conclusions: A high VIS in patients with sepsis receiving V-V ECMO support is associated with increased in-hospital mortality and a greater risk of complications, including bleeding, liver dysfunction, and renal injury. Optimizing hemodynamic management in patients with VIS ≥ 60 at 24 h may improve outcomes.

Figure (abstract P072) Kaplan–Meier curves for the in-hospital mortality. VIS, vasoactive-inotropic score.

P074 Effect of artificial intelligence in extracorporeal membrane oxygenation: a systematic review and meta-analysis

S Chen, L Liu, H Xue, D Hu, Y Zhu, J Wu, H Fu, S Liu

Zhongda Hospital, School of Medicine, Southeast University, Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Trauma Center, Nanjing, China

Critical Care 2026, 30 (Suppl 1): P074

Introduction: ECMO is a life-saving support for patients with severe cardiopulmonary failure, but its high complexity and resource demands necessitate innovative solutions. AI offers potential in optimizing ECMO management by enhancing clinical decision-making, predicting outcomes, and guiding initiation timing. However, challenges such as data heterogeneity and model generalizability limit its widespread adoption. To evaluate the effectiveness of AI in improving clinical outcomes in ECMO management, focusing on ECMO initiation, prognosis, and complications.

Methods: A meta-analysis following PRISMA guidelines were conducted, with literature searches for studies on AI-based ECMO prediction models between 1980 and 2024. Data extraction included AI methodologies, performance metrics, and key findings, with risk of bias was assessed using PROBAST.

Results: Of 212 initial records, 36 studies met criteria for inclusion. For ECMO initiation, the pooled AUC was 0.838 (95% CI: 0.804–0.873), and for prognosis prediction, the pooled AUC was 0.776 (95% CI: 0.755–0.797). Significant heterogeneity was observed. Subgroup analysis revealed single-center studies exhibited higher AUCs for both initiation (AUC = 0.888, 95% CI: 0.865–0.910) and prognosis prediction (AUC = 0.803, 95% CI: 0.688–0.918) compared to multi-center studies in initiation (AUC = 0.823, 95% CI: 0.782–0.864) and prognosis prediction (AUC = 0.772, 95% CI: 0.752–0.792). Key AI applications included patient identification, mortality prediction, enhancing resource allocation and decision-making. However, due to data variability and limited external validation, the pooled findings should be interpreted in light of the limitations identified.

Conclusions: AI has shown promise, albeit with significant heterogeneity, in improving ECMO management by providing predictions for initiation timing and patient outcomes. Future research should focus on enhancing model generalizability through multi-center validation, and standardizing data to reduce heterogeneity.

P075 Safety of regional nafamostat with low-dose systemic heparin in high-bleeding-risk ECMO patients

YJ Hu, J Fan, Z Zhang, F Xu

The First Affiliated Hospital of Chongqing Medical University, Department of Critical Care Medicine, Chongqing, China

Critical Care 2026, 30 (Suppl 1): P075

Introduction: Systemic anticoagulation with unfractionated heparin (UFH) is the standard of care during extracorporeal membrane oxygenation (ECMO). However, in patients with coagulation disorders or high bleeding risk, UFH may lead to life-threatening hemorrhage. This study evaluated the safety and feasibility of a dual anticoagulation strategy combining regional nafamostat mesilate with low-dose systemic UFH in high bleeding risk ECMO patients.

Methods: We conducted a retrospective case series of 8 ECMO patients with coagulopathy between January 2023 and December 2024 at our institution ICU. Patients received continuous regional nafamostat (0.5–0.75 mg/kg/h) via the ECMO circuit and low-dose UFH (4–8 U/kg/h) intravenously. Clinical outcomes, anticoagulation parameters (ACT/APTT), bleeding/thrombotic events, and oxygenator performance were evaluated.

Results: No thrombotic events or oxygenator-related clots were observed. Three patients experienced minor bleeding (37.5%), but none had major hemorrhage. ACT and APTT remained within acceptable ranges (Figure). The combination strategy reduced UFH requirements without compromising circuit patency.

Conclusions: In high bleeding risk ECMO patients, combining regional nafamostat with low-dose UFH appears to be a safe, individualized anticoagulation alternative. Prospective studies are warranted to validate these findings.

Figure (abstract P075) Anticoagulation profile in ECMO patients. A. Mean and median activated clotting time (ACT) with standard deviation in eight ECMO patients. B. Mean and median activated partial thromboplastin time (APTT) with standard deviation in the same patient cohort.

P076 Clinical outcomes and complications of extracorporeal membrane oxygenation in adult patients with COVID-19 in Central and Eastern Europe: a systematic review and meta-analysis

K Szuldrzynski 1 , M Jankowski 1 , Z Molnar 2 , J Benes 3 , A Piasecki 4 , M Matuszewski 1 , Z Ruszkai 5 , J Kletecka 3 , K Zuzda 1 , K Adamczyk 1

1 National Medical Institute of the Ministry of the Interior and Administration, Department of Anaesthesiology and Intensive Care, Warsaw, Poland, 2 Semmelweis University, Department of Anaesthesiology and Intensive Care, Budapest, Hungary, 3 Charles University, Department of Anaesthesiology and Intensive Care, Medical Faculty in Pilsen, Prague, Czech Republic, 4 University of Gothenburg, Gothenburg, Sweden, 5 Flór Ferenc Hospital County Pest, Department of Anaesthesiology and Intensive Care, Kistarcsa, Hungary

Critical Care 2026, 30 (Suppl 1): P076

Introduction: Extracorporeal membrane oxygenation (ECMO) serves as rescue therapy for severe COVID-19-related acute respiratory distress syndrome (ARDS). While early international data suggested 37–40% mortality [1, 2], outcomes varied across regions. Comprehensive data from Central and Eastern Europe (CEE) remain limited. This systematic review aimed to assess clinical outcomes and complications of ECMO in adult COVID-19 patients across CEE countries participating in SepsEast initiative (www.sepseast.com).

Methods: The review was registered with PROSPERO (CRD420251077593). Following PRISMA guidelines, we searched PubMed, Scopus, Embase, and Web of Science for studies reporting ECMO outcomes in adult COVID-19 patients from CEE. Studies with ≥ 10 patients were included. Quality assessment used JBI critical appraisal tools. Primary outcome was in-hospital mortality. Collected data also included ICU severity scores, mechanical ventilation duration before ECMO, ECMO duration, ICU stay, and complications. Random-effects meta-analyses were performed.

Results: Twelve studies with 802 patients from six CEE countries were included. Pooled in-hospital mortality was 65% (95%CI: 57%-72%), higher than benchmarks (37–52%) [1–3], with regional variation (Figure) from 54% (Czech Republic) to 76% (Poland). Mean SOFA score was 8.1, APACHE II 24.5. Mechanical ventilation before ECMO averaged 4.8 days, ECMO duration 17.7 days, ICU stay 23.6 days. Bleeding was reported in 40.2% of patients.

Conclusions: Mortality among COVID-19 patients receiving ECMO in CEE (65%) was higher in comparison to international registries and studies, with significant inter-country variation. Greater standardization in training, education, and clinical performance is necessary to maximize the benefit of this resource-intensive procedure in the region.

References Ramanathan K et al. Crit Care 2021;25:211 Barbaro RP et al. Lancet 2020;396:1071-1078 Ling RR et al. Crit Care 2022;26:147

Figure (abstract P076) Forest plot of in-hospital mortality in the CEE ECMO cohort. Subgroup analysis by country (Czech Republic, Hungary, Poland, and Croatia)

P077 The outcome of acute respiratory distress syndrome (ARDS) patients supported with extracorporeal carbon dioxide removal (ECCO 2 R) in Hong Kong

SW Sin 1 , S Chen 1 , J Suen 2 , HP Shum 3 , T Liong 4 , C Chan 4 , CK Tong 5 , G Ng 6 , P Tsai 7 , X Wang 8

1 University of Hong Kong, Critical Care Medicine Unit, Hong Kong, Hong Kong, China, 2 The University of Queensland, Faculty of Health, Medicine and Behavioural Sciences, Queensland, Australia, 3 Pamela Youde Nethersole Eastern Hospital, Intensive Care Unit, Hong Kong, Hong Kong, China, 4 United Christian Hospital, Intensive Care Unit, Hong Kong, Hong Kong, China, 5 Tuen Mun Hospital, Intensive Care Unit, Hong Kong, Hong Kong, China, 6 Queen Elizabeth Hospital, Intensive Care Unit, Hong Kong, Hong Kong, China, 7 Hong Kong Sanatorium Hospital, Intensive Care Unit, Hong Kong, Hong Kong, China, 8 Peking University Shenzhen Hospital, Intensive Care Unit, Shenzhen, China

Critical Care 2026, 30 (Suppl 1): P077

Introduction: ARDS is one of the leading causes of mortality of acute respiratory failure in ICU mortality exceeding 30%. While extracorporeal membrane oxygenation (ECMO) is used for severe, potentially reversible ARDS, its application is limited by resource availability and patient selection—often excluding elderly and immunocompromised patients. ECCO₂R, a less invasive and resource-intensive alternative, may benefit these patients. This study evaluates the outcomes of ECCO₂R in ARDS patients.

Methods: In this multicenter retrospective study involving seven ICUs, we included ARDS patients (> 18 years) treated with ECCO₂R. Data collected included demographics, disease severity, ICU stay, blood gases, and ventilatory parameters. The Standardized Mortality Ratio (SMR) was calculated by comparing observed mortality to predicted mortality using the Respiratory ECMO Survival Prediction (RESP) score [1].

Results: Thirty patients were treated with low-flow ECCO₂R with characteristic and outcome presented in the attached table. Key findings and additional analysis include:

1)The overall SMR was 1.19 (95% CI: 0.71–1.89, p = 0.52), indicating no significant difference between observed and predicted mortality.

2)Relative Brier score analysis yielded a ratio of 1.8 (< 2), further supporting ECCO₂R as a viable alternative.

Limitations: Small sample size and retrospective analysis.

Conclusions: ECCO₂R offers survival outcomes comparable to those seen in ARDS patients who are traditionally contraindicated for ECMO. Further prospective studies are needed to confirm its clinical utility.

Reference Schmidt M et al. Am J Respir Crit Care Med 2014;189:1374–1382

Table (abstract P077) The outcome of ARDS patients on ECCO 2 R

P078 ECCO₂R integrated with renal replacement therapy for acute hypercapnic respiratory failure: a systematic review and meta-analysis

Y Albuquerque Pessoa dos Santos 1 , P Lins 2 , P Rocha 3 , F Ramos 4 , E Lyra 4 , L Pastore 4 , B Tomazini 4 , E Costa 4 , V Campos 4 , T Silva 4

1 Hospital Sírio Libanês, ICU, São Paulo, Brazil, 2 Universidade Federal de São Paulo, São Paulo, Brazil, 3 Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil, 4 Hospital Sírio Libanês, São Paulo, Brazil

Critical Care 2026, 30 (Suppl 1): P078

Introduction: Extracorporeal CO₂ removal (ECCO₂R) integrated into renal replacement therapy (RRT) has emerged as a pragmatic option for patients with acute hypercapnic respiratory failure and acute kidney injury (AKI). Its physiological effects, however, remain incompletely defined. We aimed to synthesize its physiological impact, particularly PaCO₂ reduction, pH response, and the ability to facilitate lung-protective ventilation.

Methods: This systematic review and meta-analysis was registered in PROSPERO (CRD420251234033). We included studies evaluating ECCO₂R integrated into continuous RRT in adults with hypercapnic respiratory failure and AKI. The primary outcome was the change in PaCO₂ and pH within the first 24 h of ECCO₂R–RRT. Secondary outcomes included changes in ventilatory parameters, ventilator-free days, and reported mortality. Pre–post changes at 2 h, 24 h and 48 h were pooled using random-effects models (REML with Hartung–Knapp adjustment). Heterogeneity was assessed using I 2 .

Results: Seven studies (112 patients) were included. ECCO₂R–RRT produced an early decline in PaCO₂: − 7.16 mmHg at 2 h (95%CI − 14.92 to 0.59; I 2 = 79%), − 5.93 mmHg at 24 h (95%CI − 9.53 to − 2.34; I 2 = 0%), and − 4.35 mmHg at 48 h (95%CI − 10.47 to 1.78; I 2 = 59%) (Figure). pH increased progressively (+ 0.04 at 2 h, + 0.09 at 24 h, + 0.11 at 48 h), indicating gradual acidemia correction. Across studies, ECCO₂R–RRT was consistently associated with reductions in tidal volume, driving pressure, or minute ventilation without compromising pH. Data on ventilator-free days and mortality were heterogeneous and limited but did not suggest worsening clinical outcomes.

Conclusions: ECCO₂R integrated into RRT provides early physiological improvement in hypercapnic AKI, combining PaCO₂ reduction with stabilization of pH while allowing reduced ventilatory intensity. This hybrid strategy appears physiologically advantageous and may facilitate safer lung-protective ventilation, although larger controlled studies are needed to define its clinical role.

Figure (abstract P078) Forest plot showing pooled mean differences in PaCO₂(ΔPaCO₂) at 2 h, 24 h and 48 h after initiation of ECCO₂R integrated into renal replacement therapy

P079 Extracorporeal membrane carbon dioxide removal in patients with acute respiratory distress syndrome: impact of blood flow rate in ECCO 2 R on ventilator tidal volume reduction

D Ngoc Son, B Van Cuong, V Xuan Toan, N Van Trong, H Minh Hoan, P The Thach, V Quang Trung, N Tu Anh, N Cong Tan

Bach Mai Hospital, Center for Critical Care Medicine, Ha Noi, Viet Nam

Critical Care 2026, 30 (Suppl 1): P079

Introduction: ECCO 2 R (extracorporeal carbon dioxide removal) is a technique designed to facilitate the removal of carbon dioxide from the body, which is allowed for ultra-protective ventilation strategies with lower tidal volumes (Vt) in ARDS patients [1]. Higher blood flow improves CO 2 removal, allowing for lower tidal volumes (Vt) on mechanical ventilators, reducing ventilator-induced lung injury (VILI) while maintaining adequate ventilation.

Methods: A prospective, intervention study was conducted in severe and moderate ARDS patients supported with ECCO 2 R in the Center for Critical Care Medicine, Bach Mai hospital from August 2023 to March 2025. We used the Prismax machine and PrismaLung + with area 0.8 m 2 .

Results: A total of 15 patients were included in our study with an average age of 61.0 ± 11.9 years (min 34, max 77), males accounted for 73.3%. Patients were divided into 3 groups according to blood flow (BF): 7 patients in the < 350 mL/min group, 3 patients in the 350–399 mL/min group, and 5 patients in the ≥ 400 mL/min group. Before ECCO 2 R, mean tidal volume was 6.5 ± 0.8 mL/kg. After 2 days of ECCO 2 R, Vt decreased significantly in all groups (Figure). In the < 350 mL/min group, Vt decreased from 6.5 ± 0.8 to 5.6 ± 1.0 mL/kg. In the 350–399 mL/min group, Vt decreased from 6.8 ± 0.7 to 5.5 ± 0.7 mL/kg. In the ≥ 400 mL/min group, Vt decreased from 6.6 ± 1.0 to 5.5 ± 1.3 mL/kg. At 24 h, the reduction in Vt was 0.4 mL/kg in the < 350 mL/min group, 1.3 mL/kg in the 350–399 mL/min group, and 0.9 mL/kg in the ≥ 400 mL/min group.

Conclusions: During ECCO 2 R, higher ECCO 2 R blood flow rates were associated with the reduction of ventilator tidal volume. We suggest that blood flow rates in ECCO₂R should be maintained above 350 mL/min to ensure effective carbon dioxide removal in ARDS patients.

Reference

Monet C et al. Crit Care 2024;28:433

Figure (abstract P079) Comparison of Vt changes over time between blood flow groups

P080 Comparing 60 mEq/L bicarbonate CRRT with 40 mEq/L CRRT + ECCO₂R during progressive tidal-volume reduction in severe AKI

Y Albuquerque Pessoa dos Santos 1 , B Besen 2 , L Cardozo 3 , P Mendes 3 , M Park 3

1 Hospital Sírio Libanês, ICU, São Paulo, Brazil, 2 Universidade Federal de São Paulo, ICU, São Paulo, Brazil, 3 Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, ICU, São Paulo, Brazil

Critical Care 2026, 30 (Suppl 1): P080

Introduction: Severe acute kidney injury (AKI) frequently coexists with acute respiratory distress syndrome, where combined metabolic and respiratory acidosis may limit protective ventilation. Bicarbonate-enriched continuous renal replacement therapy (CRRT) and extracorporeal CO₂ removal (ECCO₂R) are potential strategies to optimize pH, but their comparative physiological effects remain uncertain. We evaluated these two approaches in an experimental model of severe AKI undergoing protocolized hypoventilation with stepwise tidal-volume reduction.

Methods: Twelve pigs with surgically induced AKI were randomized to receive either very-high–bicarbonate CRRT (60 mEq/L dialysate) or high–bicarbonate CRRT (40 mEq/L) combined with low-flow ECCO₂R. Ventilation was reduced every two hours targeting pH ≥ 7.2 over 12 h. Primary outcomes were lowest tidal volume (Vt) achieved and time to vasopressor initiation. Hemodynamic, respiratory, and metabolic variables were serially collected.

Results: Both strategies maintained pH ≥ 7.2 and enabled ~ 50% Vt reduction (3.7 [3.5–5.1] vs 4.8 [4.0–5.5] mL/kg; p = 0.756). Time to vasopressor initiation was similar (HR 0.76; 95%CI 0.21–2.71; Figure, panel A). Survival during the 12-h protocol also did not differ (HR 5.65; 95%CI 0.62–51.21; Figure, panel B). Both groups developed progressive hypotension requiring norepinephrine, while cardiac output remained stable. CO₂ accumulation was more pronounced with the 60 mEq/L CRRT strategy, whereas ECCO₂R attenuated PaCO₂ and bicarbonate rise.

Conclusions: CRRT with 60 mEq/L bicarbonate and CRRT + ECCO₂R using 40 mEq/L bicarbonate demonstrated comparable short-term pH control, ventilatory feasibility, hemodynamic behavior, and survival. High-bicarbonate CRRT may offer a simpler alternative when ECCO₂R is unavailable, although longer-term effects warrant further investigation.

Figure (abstract P080) Kaplan–Meier curves. Panel A: Probability of remaining alive and free from norepinephrine use. Panel B: Overall survival probability, irrespective of vasopressor requirement.

P081 Thoracic fascial plane blocks in cardiac anesthesia—systematic review and meta-analysis

SF Tünde, Á Csomós 2 , Z Molnár 3 , K Csöke-Kabai 2 , D Laczkó 2 , C Turan 2 , P Hegyi 2

1 Hospital of the Hungarian Defence Forces, Department of Anaesthesiology and Intensive Care, Bupapest, Hungary, 2 Semmelweis University, Centre for Translational Medicine, Budapest, Hungary, 3 Semmelweis University, Department of Anaesthesiology and Intensive Therapy, Budapest, Hungary

Critical Care 2026, 30 (Suppl 1): P081

Introduction: The increasing number of cardiac surgeries requires new anesthetic approaches to ensure enhanced patient recovery. Thoracic fascial plane blocks (TPBs) are safe and effective additions to conventional analgesia; the evidence for their role in cardiac analgesia is lacking. This systematic review and meta-analysis aim to find the possible role of additional TPBs in cardiac analgesia.

Methods: We conducted our systematic search in three databases (PubMed, Embase, Cochrane) on November 4, 2024 (PROSPERO ID CRD42024601988). We included 70 randomized controlled studies investigating adults undergoing cardiac surgery and receiving TPB in addition to conventional analgesia, in a total of 4632 patients (2318 intervention, 2314 control group). Other study types, studies comparing two types or combining TPBs, and pediatric patients were excluded. Data were pooled using a random-effects model, and the pooled mean difference (MD) and odds ratio (OR) with 95% confidence interval (CI) were calculated.

Results: TPBs administered before the surgical incision significantly reduced intraoperative fentanyl requirements by 271.38 µg (CI 95% (-370.99) – (-171.76); p < 0.001) [Figure]. Data showed lower VAS scores in the TPB group at the 12th postoperative hour, especially during coughing (-1.34; CI 95% (-2.01)–(-0.67); p = 0.001). TPBs were associated with faster extubation (-1.56 h; CI 95% (-2.28) – (-0.94); p < 0.001) and shorter ICU stay (-0,38 days; CI 95% (-0.54) – (-0.23); p < 0.001).

Conclusions: Our results suggest that additional TBPs are safe and effective in enhancing recovery in cardiac surgery. However, analgesia of minimally invasive approaches needs to be further investigated.

Figure (abstract P081) Intraoperative fentanyl consumption in micrograms, results are expressed in MD with 95% CI, subgroup analysis is based on the administration of the thoracic fascial plane block

P082 Exploring a multi-parameter technology for pain assessment in adult intensive care: the nociception level index (NOL)

C Gélinas 1 , R Kagie 2 , S Shahiri 1 , HT Wang 3 , MC Gallani 4 , W Oulehri 5 , D Laporta 6 , P Richebé 7

1 McGill University, Ingram School of Nursing, Montreal, Canada, 2 Jewish General Hospital, Centre for Nursing Research, Montreal, Canada, 3 CHUM, Division of Intensive Care, Montreal, Canada, 4 Université Laval, Faculty of Nursing, Quebec City, Canada, 5 University Hospital of Strasbourg, Anesthesiology and Intensive Care Medicine, Strasbourg, France, 6 McGill University, Medicine Respiratory Division, Montreal, Canada, 7 Polyclinic Bordeaux Nord Aquitaine, Anesthesia and Resuscitation, Bordeaux, France

Critical Care 2026, 30 (Suppl 1): P082

Introduction: Pain is complex to assess in the adult intensive care unit (ICU). Many ICU patients cannot communicate their pain through self-report or behaviors, highlighting the need for alternative measures. Initially developed for anesthesia, the Nociception Level Index (NOL) is a multi-parameter technology capturing several parameters and their variability (i.e., heart rate, plethysmography, skin conductance and temperature). This study aimed to describe the validity of the NOL for ICU pain assessment.

Methods: An observational design was conducted in 3 ICUs in Montreal, Canada. ICU patients were assigned to one group according to their communication ability: a) Able to self-report (Group A), b) Able to express behaviors (Group B), and c) Unable to self-report and to express behaviors (Group C). NOL values were obtained at baseline (rest), during non-noxious (soft touch, and non-invasive blood pressure [NIBP]) and noxious stimulation (e.g., suctioning or turning). Group A was asked to provide their self-report of pain intensity (0–10 Pain Thermometer), and behaviors were rated using the 0–8 Critical-Care Pain Observation Tool (CPOT) in Group A and B during the noxious stimulation.

Results: A total of 91 ICU patients were enrolled (Group A: 42; Group B: 35; Group C: 14) with 33% female, mean age of 61, and mostly from North America or Europe (73%). Admissions were medical (50%) or surgical (42%) with a median ICU length of stay of 15 days (interquartile range or IQR = 4–36); half of them received opioids during data collection. Across all groups, median NOL values increased from 7.5 (IQR = 3–14) at baseline, to 8 (IQR = 2–16) at soft touch, 11 (IQR = 4–20) at NIBP and 28 (IQR = 18–40) during noxious stimulation (Friedman test, p < 0.001). NOL values were correlated with self-reported pain intensity (rho = 0.66, p = 0.002)) and CPOT scores (rho = 0.35, p = 0.005) but only during suctioning.

Conclusions: The NOL could detect noxious stimulation and was associated with pain scores in ICU patients.

P085 Efficacy and safety of remimazolam tosylate versus propofol for sedation of mechanically ventilated patients in intensive care units: a multicenter, randomized, single-blind, non-inferiority, phase 3 trial

N Liu 1 , M Chen 2 , X Guan 2 , F Lin 3 , J Yu 4 , M Yang 5 , Q Zhou 6 , K Chen 7 , H Zhao 8 , L Tang 8

1 The First Affiliated Hospital of Sun Yatsen University, Department of Critical Care Medicine, Guangzhou, China, 2 The First Affiliated Hospital of Sun Yatsen University, Guangzhou, China, 3 Fujian Provincial Hospital, Fuzhou, China, 4 Tianjin Nankai Hospital, Tianjin Medical University, Tianjin, China, 5 Qujing No.1 Hospital, Qujing, China, 6 Peking University Shougang Hospital, Beijing, China, 7 Jinhua Central Hospital, Jinhua, China, 8 Jiangsu Hengrui Pharmaceuticals Co., Ltd., Shanghai, China

Critical Care 2026, 30 (Suppl 1): P085

Introduction: Remimazolam tosylate, a novel short-acting benzodiazepine, has shown effective and safe sedation in mechanically ventilated patients in intensive care units (ICU) in a phase 2 trial. We conducted a multicenter, randomized, single-blind, actively controlled, non-inferiority phase 3 trial ( NCT06222294 ) for further evaluation.

Methods: Mechanically ventilated patients, requiring sedation for 6–24 h with a target Richmond Agitation–Sedation Scale (RASS) of -2 to 1, were randomized (1:1) to receive intravenous remimazolam tosylate (loading dose, 0.08 mg/kg; maintenance, 0–2.0 mg/kg/h) or propofol (loading dose, 0.3–0.5 mg/kg; maintenance, 0.3–4.0 mg/kg/h). Both allowed for adjusted infusion rates or given additional doses to maintain target RASS. Primary endpoint was sedation success rate, defined as the percentage of time maintaining target sedation range ≥ 70% of study drug administration time without rescue sedation. Non-inferiority margin was -8%.

Results: 211 randomized patients completed the trial (remimazolam tosylate, n = 106; propofol, n = 105). Sedation success rate was 98.1% with remimazolam tosylate and 96.2% with propofol (difference 1.9%, 95% CI -3.3% to 7.8%). Percentage of time in RASS target range and proportion of patients receiving rescue sedation were comparable. Mean (SD) number of additional doses required was 0.03 (0.17) for remimazolam tosylate and 0.18 (0.77) for propofol. Incidence of AE was 76.4% with remimazolam tosylate and 73.3% with propofol; all cases were mild to moderate, except one severe with propofol. Hypotension led to dose interruption in 1 patient in each group; bradycardia incidence was similar. The mean terminal half-life of remimazolam was generally consistent with that observed in a healthy human pharmacology study (1.97 ± 1.62 h vs. 1.76 ± 0.76 h), which involved a 2h remimazolam tosylate infusion.

Conclusions: Remimazolam tosylate demonstrated non-inferiority to propofol with good tolerance and efficacy for sedation of mechanically ventilated patients in ICU.

P087 Evaluating the use and safety of intravenous olanzapine at a level I pediatric trauma center emergency department and pediatric ICU

AS Mujeeb, ML Albrecht, JL Jantzer, JT Jancik

Hennepin Healthcare, Pharmacy, Minneapolis, USA

Critical Care 2026, 30 (Suppl 1): P087

Introduction: Intravenous olanzapine (OLZ) is not FDA approved for use in children. Pediatric-specific evidence for the safety of IV OLZ is limited, especially in children < 9 years of age. One review found that IV and IM OLZ were effective and well-tolerated when used in the ED for acute agitation in patients ages 9–18 years [1]. Another case series highlighted safe administration of IV OLZ in an 8-year-old patient, with minimal adverse events and no serious complications [2]. This study aims to characterize the use and safety of IV OLZ among pediatric patients ≤ 8 years of age.

Methods: This single-center retrospective observational cohort study included patients admitted from 1/7/2021 to 1/7/2025. The primary outcome was the incidence of IV OLZ administration in patients ≤ 8 years of age. Secondary outcomes included the incidence of bradycardia, hypotension, hypoxia, intubation, and QTc prolongation.

Results: We included 14 patients who ranged in age from 1–8 years. There were 33 IV OLZ administrations. The most common dose was 1.25 mg. Bradycardia was the most common adverse event occurring in 71.4% of patients, but no interventions were required. Hypotension occurred in 2% of patients, but vasopressors were not required. Prior to IV OLZ administration, 64.3% of patients were intubated. No patients experienced hypoxia or required intubation as a result of IV OLZ. Baseline EKGs were obtained in 43% of patients; 14.3% received a repeat EKG, and no patients had a prolonged QTc interval.

Conclusions: In children ≤ 8 years old, IV OLZ seemed to be well tolerated with bradycardia being the most common adverse effect.

References Cole JB et al. Pediatr Emerg Care 2020;36:70-76 Hassan A et al. J Pediatr Pharmacol Ther 2023;28:752-756

P088 Safety of olanzapine doses greater than 30 mg within 24 h in the medical intensive care unit

JA Lloyd, KA Considine, JT Jancik

Hennepin Healthcare, Pharmacy, Minneapolis, USA

Critical Care 2026, 30 (Suppl 1): P088

Introduction: Intravenous olanzapine (OLZ) is not FDA-approved for agitation or delirium but is often used for this indication [1]. Studies have not shown an improvement in outcomes with antipsychotics, but most providers support their use [2]. The safety of total daily doses > 30 mg from all routes and IV OLZ doses > 20 mg within 24 h have not been evaluated. The maximum FDA-approved daily dose is 20 mg IM or enteral. The purpose of this study was to examine the incidence of cumulative OLZ doses > 30 mg (enteral, IV/IM) in MICU patients who received > 20 mg IV OLZ within 24 h and assess potential side effects.

Methods: This was a single-center retrospective observational cohort study from 1/7/2023 to 30/6/2025. The primary outcome was the incidence of OLZ doses > 30 mg within 24 h. Patients were included if they received > 20 mg IV OLZ within 24 h with at least 1 dose of ≥ 10 mg in the MICU. Secondary outcomes included average OLZ dosing and the incidence of hypotension, bradycardia, hypoxia, and QTc prolongation.

Results: There were 67 patient encounters with 44 having cumulative daily doses > 30 mg from all routes, of which 41 solely received IV OLZ. The average cumulative IV OLZ dose was 35 mg within 24 h. Hypotension occurred in 24% of patients with 4% requiring vasopressors. Hypoxia occurred in 12% of patients. Of all encounters, 84% were intubated prior to receiving > 20 mg IV OLZ within 24 h, 6% were subsequently intubated, and 10% were never intubated. There were no incidences of bradycardia requiring intervention. Prolonged QTc post-OLZ was seen in 4% of encounters with no episodes of torsades de pointes.

Conclusions: In a MICU population, cumulative OLZ doses > 30 mg were common among those who received > 20 mg IV OLZ within 24 h. Hypotension was the most common adverse effect.

References Lorenzo MP et al. Hospital Pharmacy 2020;55:109-111 Grover S et al. Indian J Psychiatry 2018;60:S329-S340

P090 Multi-center prospective observational study of current analgo-sedation practices and the incidence of delirium in Indian ICUs

S Bhosale 1 , A Kulkarni 2

1 ACTREC, 22 Owe Village Kharghar, Critical Care Medicine, Mumbai, India, 2 ACTREC, 22 Owe Village Kharghar, Critical Care Medicine, Tata Memorial Centre, HBNI, Mumbai, India

Critical Care 2026, 30 (Suppl 1): P090

Introduction: Delirium is a neuropsychiatric syndrome shown to prolong mechanical ventilation, duration of ICU and hospital length of stay and in some studies, even mortality [1,2]. At present, the knowledge regarding current sedation practices and the incidence of delirium in the Indian ICUs is lacking.

Methods: Patients more than 18 years with an anticipated duration of ventilation of more than 48 h, need for sedation for more than 48 h were recruited in the study. These patients were followed up for 30 days (or until discharge from the hospital or death). The patients eligible for the study had a CAM-ICU score evaluated every 8 h to detect delirium.

Results: A total of 885 patients were included, out of which 538 (61%) patients had delirium. Mortality was higher in patients with delirium compared to patients who did not ( 21% vs 13%). The median Apache score was higher in patients with delirium (16 (IQR 12, 22) vs 14 (IQR 11, 20) The percentage of patients who remained in the desired -2 to 0 range was less in the delirium group (58% vs 66%) The median length of stay was higher in delirium group 6.0 (IQR 4.0, 10.0) vs 5.0 (IQR 3.0, 9.0)There was no difference in the duration of mechanical ventilation in patients with delirium compared to patients who did not have delirium. In multivariable risk regression analysis, age (odds ratio 1.66 (1.20–2.30, p = 0.002), male sex ( OR 1.48 (CI 1.06 -2.07 p = 0.022), use of prescription meds (2.33. 1.29–4.44 p = 0.007), use of vasopressors (1.81, 1.13, 2.95 p = 0.015), Sofa score (1.55, 1.11, 2.16 p = 0.01) were independent risk factors for delirium.

Conclusions: Delirium remains a significant occurrence in the ICU and is associated with poor outcomes. Several risk factors for delirium are linked to the development of delirium in the intensive care unit.

References Marcantonio ER. N Engl J Med 2017;377:1456–1466 Salluh JI et al. BMJ 2015;350:h2358

P091 Continuation versus discontinuation of renin–angiotensin–aldosterone system inhibitors in patients undergoing major non-cardiac surgery-systematic review and meta-analysis

ZW Weber 1 , C Turan 1 , SF Tünde 2 , L Zubek 1 , Z Molnár 1 , E Zima 1

1 Semmelweis University, Department of Anaesthesiology and Intensive Therapy, Budapest, Hungary, 2 Hospital of the Hungarian Defence Forces, Department of Anaesthesiology and Intensive Care, Budapest, Hungary

Critical Care 2026, 30 (Suppl 1): P091

Introduction: Many patients undergoing major non-cardiac surgery are chronically treated with angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) for hypertension or chronic heart failure. Perioperative management of these drugs remains controversial, as both continuation and discontinuation may lead to adverse outcomes. This study aimed to assess which strategy—continuation or discontinuation—is safer.

Methods: A systematic literature search was performed in CENTRAL, PubMed, and Embase on November 10, 2024, according to a registered PROSPERO (ID: CRD42024607744) protocol. Eligible studies included randomized controlled trials (RCTs) and observational studies of adult patients chronically treated with ACEIs or ARBs and undergoing major non-cardiac surgery. Studies comparing continuation versus discontinuation and reporting at least one predefined outcome were included. The risk of bias was assessed using the ROB2 tool for RCTs and ROBINS-I for observational studies.

Results: Sixteen studies with a total of 74,032 patients met the inclusion criteria, including seven observational studies, seven RCTs, and two post-hoc analyses. Data from six RCTs showed a significantly higher incidence of intraoperative episodes of hypotension (OR: 1.33, 95% CI: 1.20–1.47, p < 0.0001) in the continuation group (Figure). Other outcomes, such as myocardial injury after non-cardiac surgery (MINS) (OR:1.09, 95%CI: 0.95–1.24, p = 0.276) and mortality (OR: 0.91, 95% CI: 0.8–1.03, p = 0.104), were not statistically significant but tended to be higher in the continuation group.

Conclusions: Continuation of ACEIs or ARBs before major non-cardiac surgery is associated with a higher risk of intraoperative hypotension. Further studies are needed to determine optimal discontinuation timing and identify subgroups that may benefit from continuation.

Figure (abstract P091) Forest plot of RCTs representing intraoperative episodes of hypotension. OR: odds ratio, CI: confidence interval

P092 Epidemiology, outcomes and risk factors for mortality or severe postoperative complications in cardiac surgery patients admitted to intensive care units in Brazil: a multicenter observational study

R Carneiro de Freitas Chaves, N Naiara Barros de Vasconcelos, A José Pereira, T Domingos Corrêa, JM Silva Júnior

Hospital Israelita Albert Einstein, Critical Care Medicine, São Paulo, Brazil

Critical Care 2026, 30 (Suppl 1): P092

Introduction: Cardiac surgery carries substantial risks of perioperative complications and mortality, yet outcome data from low- and middle-income countries are scarce. This study evaluated the incidence of early mortality and major postoperative complications in patients undergoing cardiac surgery in Brazil.

Methods: The study was registered at ClinicalTrials.gov ( NCT06154473 ) and the protocol with the statistical analysis plan was published before completion of patient enrolment [1]. This multicenter prospective study included adults (≥ 18 years) undergoing cardiac surgery who require postoperative care in ICU. The primary outcome was the risk factors and incidence of mortality or severe postoperative complications within the first 3 postoperative days or until ICU discharge (whichever occurs first). Risk factors were assessed using generalized linear mixed-effects models with a binomial distribution and an identity link function, accounting for the study center as a random intercept to adjust for clustering, reported as odds ratios (OR) with 95% confidence intervals (CI).

Results: Between September 2023 and March 2025, 528 patients were enrolled across 11 hospitals in Brazil. Among 528 patients (91% open-heart and 9% percutaneous procedures, mainly CABG and valve replacements), 170 (32%) experienced early mortality or severe postoperative complications, most within the first 24 h (132 of 170, 78%). The most frequent complications were severe hemodynamic instability (126, 24%) ARDS (71, 13%), and severe bleeding (33, 6%). Risk factors included prior stroke, preoperative thrombocytopenia, open-heart surgery, biological valve use, higher SOFA scores, lower arterial pH, and postoperative vasoplegia (Figure).

Conclusions: In this large multicenter cohort of cardiac surgery patients in Brazil, one in three experienced early mortality or severe postoperative complications, mostly within the first 24 h.

Reference Vasconcelos NNB et al. Crit Care Sci 2025;37:e20250222

Figure (abstract P092) Factors related to the risk of mortality or severe postoperative complications. Data are presented as mean ± standard deviation or as counts with percentages [n (%)]. A vertical reference line was plotted at 1. Abbreviations. CI = confidence interval. OR = odds ratio.

P094 EA-230 attenuates the duration of clinically relevant postoperative complications in on-pump cardiac surgery patients: a post hoc analysis of a phase 2b study

S Van Doren 1 , M Kox 1 , G Wensvoort 2 , P Pickkers 1

1 Radboudumc, Intensive Care, Nijmegen, Netherlands, 2 Exponential Biotherapies, Inc. EBI, The Hague, Netherlands

Critical Care 2026, 30 (Suppl 1): P094

Introduction: In the phase 2b EASI study [1], administration of the PAMP/DAMP signaling attenuator EA-230 during on-pump cardiac surgery improved hemodynamic stability and attenuated organ dysfunction. Additionally, EA-230 significantly reduced hospital and ICU length of stay (LoS). We investigated whether or not these findings could be explained by a shorter duration of clinically relevant Post-Operative Complications (POCs).

Methods: By double-blinded post hoc analysis of the EASI study, adverse events were adjudicated according to the European Perioperative Clinical Outcome (EPCO) definitions [2] to assess POCs. Following EPCO definitions, POCs are determined as clinically relevant when they require specific clinical treatment. POC incidence, severity and duration were compared to LoS and between EA-230 and placebo groups.

Results: Of 179 patients, 110 developed ≥ 1 POC; predominantly arrhythmias, delirium, and infections. Although reduced incidence and severity-scores of POCs were found in the active versus placebo group, these did not reach statistical significance. EA-230 compared to placebo significantly attenuated the duration of clinically relevant POCs (median [IQR] 17.2 [9.4–32.0] vs 44.3 [10.1–171.0] hrs; p = 0.003). Patients with ≥1 POC had a significantly longer hospital LoS compared to those without POCs (median [IQR] 24 [20.0-146.0] vs 220 [189-282] hrs; p = 2e-16). In linear regression of log-transformed hospital LoS in patients with defined POC duration (R2 0.336), longer POC duration was associated with longer hospital LoS (β [95% CI] 1.05 [1.03-1.07] per 24 hr increase; p <0.001), whereas treatment with EA-230 was associated with reduced LoS (β [95% CI] 0.73 [0.60-0.88]; p = 0.002). Accordingly, in a Cox proportional hazard model including cumulative POC duration as a time dependent covariate for the population with no POCs and POCs of defined duration, longer POC duration was associated with a lower hazard of discharge (HR [95% CI] 0.87 [0.79-0.96] per 24 hr increase; p = 0.005), while treatment with EA-230 was linked to an increased hazard of discharge (HR [95% CI] 1.46 [1.03-2.09]; p = 0.036).

Conclusions: Intraoperative treatment with EA-230 significantly attenuates the duration of clinically relevant POCs. This plausibly accounts for the previously reported shorter hospital LoS.

References van Groenendael R et al. Crit Care Med 2021;49:790–803 Jammer I et al. Eur J Anaesthesiol 2015;32:88-105

P096 Perioperative oxygenation, cardiac rhythm disturbances, and hypotension in nonagenarian surgical patients

G Madrid, AL Delgadillo, A Romero, A Ojeda

Hospital Universitario Fundacion Santa Fe de Bogota, Anestesiologia, Bogotá, Colombia

Critical Care 2026, 30 (Suppl 1): P096

Introduction: Nonagenarians have markedly reduced physiological reserve, making them highly susceptible to intraoperative cardiopulmonary instability [1]. Oxygen desaturation (SpO₂ < 90%), new-onset arrhythmias, and hypotension may signal early respiratory or cardiovascular failure, yet their prognostic value in patients ≥ 90 years is unclear. This study examined whether these events were associated with postoperative complications, mortality, and recovery.

Methods: We conducted a retrospective cohort study of nonagenarian surgical patients in Colombia. Oxygenation deterioration was defined as any SpO₂ < 90% requiring intervention; arrhythmias as new rhythm disturbances requiring evaluation; and hypotension as systolic blood pressure requiring vasopressors or fluids. Primary outcomes were postoperative complications and in-hospital mortality. Secondary outcomes included vasopressor use, length of stay, delirium, and discharge disposition. Descriptive analyses were performed due to low event frequencies.

Results: Among 206 patients, oxygenation deterioration occurred in 8 (4%), arrhythmias in 14 (6.8%), and hypotension in a larger subset (Figure). All events were associated with higher postoperative complications (50–63% vs ≈22% without instability) and longer hospitalization (6–7 vs 4 days). Patients with instability required more vasopressors and had more delirium, reflecting reduced physiologic reserve. Mortality was low but proportionally higher in those with oxygenation deterioration or arrhythmias.

Conclusions: Intraoperative oxygen desaturation, arrhythmias, and hypotension, though infrequent, were strongly associated with postoperative complications, delayed recovery, and increased hemodynamic support needs in nonagenarians. Even brief instability appears to reflect profound vulnerability in this population. Enhanced monitoring and proactive management may help mitigate deterioration, highlighting the need for larger studies to guide perioperative care.

Reference Arozullah AM et al. Anesthesiology 2003;99:923–931

Figure (abstract P096) Distribution of intraoperative physiologic instability events in nonagenarians

P098 Metabolism-centered TyG and TG/HDL models for early recognition of sepsis-induced cardiomyopathy: a multi-cohort machine-learning study

ZZ Zuo, JD Dai, QH Huang, WX Xu, LZ Zhang, ZQ Qian

Xiangya Hospital, Central South University, Critical Care Medicine, Changsha, China

Critical Care 2026, 30 (Suppl 1): P098

Introduction: Sepsis-induced cardiomyopathy (SICM) is associated with high morbidity and mortality. However, effective biomarkers for predicting prognosis remain lacking.

Methods: We retrospectively assembled 2,588 adults with sepsis from MIMIC-IV and eICU. Variables obtained within 24 h of ICU admission were screened. Boruta (500 iterations) selected predictors. Five classifiers were benchmarked, and both light gradient boosting machine (LGBM) and random forest (RF) showed superior discrimination. Considering stability and interpretability, RF was selected to build three collinearity-aware pipelines: TyG-RF, TG/HDL-RF, and combined TyG + TG/HDL-RF. The final RF model underwent nested fivefold cross-validation, calibration and decision-curve analysis, and SHAP interpretation. Discrimination was assessed on a held-out internal test set with 95% CIs. External validation was performed in the Xiangya Immuno-Infection Biobank and Data Platform (n = 504). Restricted-cubic-spline (RCS) analyses explored non-linear associations and data-driven thresholds (Figure).

Results: Boruta retained 21 predictors. In the final RF pipeline, SHAP highlighted SOFA, creatinine, age, hemoglobin, TyG, TG/HDL as the most influential features (mean |SHAP|> 0.05). On the internal test set, the combined TyG + TG/HDL-RF model achieved the highest discrimination (AUC = 0.725 [95% CI 0.673–0.777]) with good calibration (intercept = 0.02; slope = 0.96), outperforming TyG-RF (AUC = 0.722) and TG/HDL-RF (AUC = 0.717). Multivariable logistic regression confirmed independent associations for TyG (OR 1.18, p = 0.001) and TG/HDL (OR 1.10, p = 0.045). RCS identified a TyG inflection around 10.21 for increased SICM risk. External validation in the XYIDB cohort yielded an AUC = 0.619, demonstrating acceptable generalizability.

Conclusions: The TyG + TG/HDL-based RF model provided the best internal discrimination and external robustness, while SHAP interpretation confirmed its biological plausibility, indicating TyG + TG/HDL-based RF model a promising tool in SICM.

Figure (abstract P098) Study framework

P099 Differential cardiac microRNA expression in gram-negative and gram-positive sepsis: insights into septic cardiomyopathy

H Säkkinen 1 , P Lehto 1 , H Syrjälä 1 , R Kerkelä 2 , S Skarp 2 , K Porvari 3 , T AlaKokko 1

1 Oulu University Hospital, Research Group of Intensive Care Medicine, Intensive Care Center, Oulu, Finland, 2 University of Oulu, Research Unit of Biomedicine and Internal Medicine Medical Research Center Oulu, Biocenter Oulu, Oulu, Finland, 3 University of Oulu, Department of Forensic Medicine, Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu, Finland

Critical Care 2026, 30 (Suppl 1): P099

Introduction: Septic cardiomyopathy (SCM) occurs in both gram-negative (GN) and gram-positive (GP) sepsis, despite distinct cytokine profiles. MicroRNAs (miRNAs) are key regulators of inflammation. To investigate SCM, we compared cardiac miRNA expression between GN and GP sepsis.

Methods: In our previous work, we identified differential expression of 32 miRNAs in cardiac autopsy samples from adult ICU patients with sepsis compared to non-septic medicolegal autopsy hearts. In this study, we analyzed miRNA expression in 4 GP sepsis hearts, 5 GN sepsis hearts, and 5 negative blood culture (NBC) hearts.

Results: GP sepsis patients had the highest APACHE II scores, procalcitonin (PCT) levels, and vasoactive-inotropic scores during the first 24 h in the ICU. miR-652-3p, which attenuates myocyte death, was upregulated in GP sepsis compared to NBC (1.4-fold change, p < 0.01). C-reactive protein (CRP) levels were highest in GN sepsis. Inflammatory promoters miR-199b-5p and miR-654-3p were upregulated in GN sepsis compared to GP sepsis (1.9-fold change, p < 0.05 for both). In GP sepsis, miR-199b-5p was downregulated compared to NBC (46% reduction in read counts, p < 0.05), along with miR-181c-3p, an inhibitor of mitochondrial COX1 (19% reduction, p < 0.05). Furthermore, miR-181a-3p (restricts vascular inflammation), miR-21-3p (promotes cardiac failure), and miR-3196 (unknown cardiac role) were upregulated in patients receiving levosimendan compared to non-receivers, though expression patterns did not differ by blood culture status.

Conclusions: GN sepsis appears to induce more intense cardiac inflammation than GP sepsis. In contrast, GP sepsis was associated with miRNA expression patterns suggesting reduced inflammation and enhanced myocyte protection, despite patients presenting with the highest risk of death at ICU admission. Myocardial miR-181a-3p, miR-21-3p, and miR-3196 were upregulated in cases of low cardiac output, regardless of the underlying pathogen.

P101 Left ventricular diastolic dysfunction in sepsis and its prognostic significance: a prospective observational study

N Wang, F Guo

Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China

Critical Care 2026, 30 (Suppl 1): P101

Introduction: Sepsis is frequently associated with cardiac dysfunction, among which left ventricular diastolic dysfunction (LVDD) plays a critical role in a significant morbidity and mortality. This study was aimed to characterize LVDD in patients with sepsis and assess its prognostic significance.

Methods: This prospective, single-center, observational study enrolled adult patients diagnosed with sepsis (Sepsis-3 definition). Patients were echocardiographically assessed within 12 h after admission, independently performed by an expert in critical care echocardiography who was unaware of patients’ outcome. LVDD was defined by the presence of a septal e’ maximal velocity < 8 cm/s and categorized by severity according to the septal E/e’ ratio. The primary outcome was 28-day mortality. Survival curves were generated using the Kaplan–Meier method.

Results: A total of 162 patients (age: 64 [53, 74] year; 57.4% male; APACHE II: 19 [14, 25]; SOFA: 8 [5, 11]) were enrolled. LVDD was observed in 50.6% of patients. 28-day mortality was statistically different between patients with and without LVDD (23/82 [28.0%] vs. 11/80 [13.8%]; HR: 2.25 [1.10–4.62]; p = 0.023). Further stratification of LVDD into mild, moderate, and severe grades revealed that patients with moderate and severe LVDD each accounted for 45.1%. Kaplan–Meier survival analysis revealed significant differences in 28-day cumulative survival among patients with different LVDD grades (Figure). Increasing LVDD severity was associated with higher 28-day mortality (X 2 = 9.035, p = 0.027) and a higher incidence of new-onset atrial fibrillation within 72 h (X 2 = 10.929, p = 0.012).

Conclusions: LVDD is significantly associated with 28-day mortality in patients with sepsis. The higher degree of diastolic dysfunction, the higher 28-day mortality and the higher risk of new-onset atrial fibrillation within 72 h.

Figure (abstract P101) Kaplan–Meier survival curves for 28-day mortality according to LVDD grades. Patients with severe LVDD had significantly lower 28-day survival than those with none or mild–moderate LVDD

P102 Assessment of septic cardiomyopathy prevalence in ICU patients with sepsis and septic shock using echocardiography-based tools.

L Puodziukaite 1 , U Parchutikaite 1 , D Kersnauskaite 2 , V Vicka 1 , J Trzebicka 3 , O Doroba 3 , M Zawadka 3 , S Glaveckaite 2 , G Davidavicius 2 , T Jovaisa 1

1 Vilnius University, Clinic of Anaesthesiology and Intensive Care, Institute of Clinical Medicine, Vilnius, Lithuania, 2 Vilnius University, Clinic of Cardiovascular Diseases, Institute of Clinical Medicine, Vilnius, Lithuania, 3 Medical University of Warsaw, 2nd Department of Anesthesiology and Intensive Therapy, Warsaw, Poland

Critical Care 2026, 30 (Suppl 1): P102

Introduction: Septic cardiomyopathy (SCM) is a reversible cardiac dysfunction that occurs in patients with sepsis or septic shock and is associated with increased morbidity and mortality. Early recognition of SCM using echocardiography-based parameters is crucial for optimizing patient management.

Methods: A multicenter, prospective observational study was conducted at tertiary reference hospitals in Lithuania and Poland between March 2024 and October 2025. Transthoracic echocardiography and hemodynamic assessment were performed within 48 h of enrolment. SCM was diagnosed using left ventricular ejection fraction (LVEF < 50% or ≥ 10% reduction from baseline), cardiac power output (CPO < 0.6W), and afterload-related cardiac performance (ACP < 80%). Statistical analysis was conducted using SPSS (version 31.0.1.0).

Results: A total of 104 patients were included. The median age was 64 [52–72] years. The median SOFA score was 10 [9–13], the mean APACHE II score was 21.8 ± 6.9, the mean SAPS II score was 48.9 ± 15.5. The median of lactate concentration was 2.96 mmol/L [1.9–5.5], and the median of maximal norepinephrine dose was 0.35 µg/kg/min [0.2–0.5]. Septic shock was diagnosed in 89 patients (85.6%). SCM was identified using these criteria: a reduced LVEF in 21 patients (20.2%), decreased CPO in 33 patients (33.3%), and impaired ACP in 29 patients (49.5%). LVEF served as the reference standard. Pearson’s Chi-square test showed no significant correlation between LVEF and CPO ( p = 0.215) or between LVEF and ACP ( p = 0.960).

Conclusions: SCM was detected in a substantial proportion of patients, with CPO and ACP identifying additional cases beyond LVEF. However, no significant correlation was observed between LVEF and the other criteria, suggesting that CPO and ACP may detect different aspects of cardiac dysfunction not captured by LVEF alone.

P103 Diastolic dysfunction in acute and critical illness: from acute pathophysiology to chronic HFpEF

A Binuraj, O ReevesChen, M De Silva Morgan, T Veenith, S Thilak, C Chacko, T Fisher, M Abbawy, J Cotton

New Cross Hospital, Intensive Care, Wolverhampton, UK

Critical Care 2026, 30 (Suppl 1): P103

Introduction: Heart failure with preserved ejection fraction (HFpEF) is a multisystem inflammatory syndrome linked to comorbidities such as obesity, diabetes, hypertension and ageing [1]. In critical illness, especially sepsis, acute diastolic dysfunction is common, but its long-term impact remain unclear [2]. This review examines evidence on mechanisms, diagnosis and clinical trajectory across acute and chronic settings.

Methods: This was a narrative review of mechanistic, echocardiographic and clinical outcome studies. Our review incorporated HFpEF pharmacotherapy trials, ICU cardiac imaging literature, and emerging diagnostic techniques e.g. AI-assisted echocardiography.

Results: HFpEF arises from comorbidity-driven inflammation causing endothelial dysfunction, microvascular disease and myocardial stiffening. Critical illness adds further insult: cytokine storm, vasoplegia and mitochondrial dysfunction impair relaxation and trigger acute diastolic dysfunction. Large cohorts show high prevalence in sepsis, many of whom develop ongoing dysfunction and elevated long-term cardiovascular risk. ICU diagnostic accuracy is limited by ventilation, fluid shifts and vasoactive therapy, with lateral e’ (a doppler tissue imaging measure) emerging as the most reliable parameter. Newer therapies: SGLT2 inhibitors, mineralocorticoid antagonists and GLP-1 receptor agonists, coupled with AI-enhanced imaging present diagnostic and therapeutic opportunities.

Conclusions: Diastolic dysfunction in critical illness reflects interplay between inflammation and cardiac vulnerability (Figure). Though often reversible, persistent dysfunction may lead to chronic HFpEF. Advances in imaging, phenotyping and targeted therapy offer promising avenues for intervention and follow-up.

References Mouton AJ et al. Circ Res 2020;126:789–806 Landesberg G et al. Eur Heart J 2012;33:895–903

Figure (abstract P103) Diastolic dysfunction in acute and critical illness, acute pathophysiology to chronic failure

P104 The HEAR score in ruling out acute coronary syndrome

Y Walha, W Demni, E Ben Mhamed, D Hamdi, F Lachtar, W Saidi, W Bahria, N Nouira

Monji Slim Hospital, Emergency Department, Tunis, Tunisia

Critical Care 2026, 30 (Suppl 1): P104

Introduction: Chest pain is a common symptoms in patients visiting the emergency department. Acute coronary syndrome (ACS) poses a diagnostic challenge for physicians. The HEAR score is a clinical tool developed to identify patients at low risk of ACS. the aim of this study was to assess the performance of the HEAR score in ruling out the diagnosis of ACS and major adverse cardiovascular events (MACE) at 6 weeks.

Methods: A prospective, observational and analytical study was conducted at the emergency department of Mongi Slim Hospital from January 2022, to September 2023, involving patients presenting with acute non-traumatic chest pain. The HEAR score was calculated for all patients, and a follow-up telephone contact was made after 6 weeks to assess for MACE.

Results: A total of 277 patients were included. The average age was 63 ± 16.5 years. The sex-ratio was 1.9. ACS was diagnosed with 27.8% of patients( 0.9% in the low-risk group). The HEAR score was predictive of ACS ( p = 0.01; adjusted OR = 1.7; CI [1.1–2.6]). AUC = 0.85. The threshold for the HEAR score to exclude ACS was < 4, with a sensitivity (98.7%), specificity (52.8%), PPV (45.6%), NPV (98.2%) and LR- (0.02). At 6 weeks, 21% of patients experienced MACE. The HEAR score was predictive of MACE ( p < 0.01; OR = 1.7; CI [1.2–2.3]). AUC = 0.74. The threshold for the HEAR score to exclude MACE at 6 weeks was < 3, with sensitivity (98.2%), specificity (33.6%), PPV (27.9%), NPV (98.7%), and LR- (0.05).

Conclusions: The HEAR score is a simple and valid clinical tool with strong discriminative power, allowing for the exclusion of ACS diagnosis in low-risk patients.

P105 Epidemiological profile and risk factors for cardiovascular related admissions to a coronary intensive care unit over a 10-year period

G Silva 1 , J Fidelis 1 , M Camargo 1 , H Valente 2 , P Morelhão 3 , CE Bosso 1

1 Universidade do Oeste Paulista UNOESTE, Medical College, Presidente Prudente, Brazil, 2 Universidade Estadual Paulista “Júlio de Mesquita Filho” UNESP, Department Physical Therapy, Presidente Prudente, Brazil, 3 Associação Fundo de Incentivo à Pesquisa AFIP, Institute, São Paulo, Brazil

Critical Care 2026, 30 (Suppl 1): P105

Introduction: The increasing demand for care in coronary intensive care units (CICU) among patients with cardiovascular diagnoses is a growing reality [1].The aim was to evaluate the epidemiological profile and risk factors associated with cardiovascular related admissions to a CICU over a 10-year period.

Methods: An epidemiological study was conducted using logistic regression analysis of data from 2014 to 2025, obtained from electronic medical records of the CICU at the Regional Hospital of Presidente Prudente, São Paulo, Brazil. The study was duly approved by the institution’s Medical Ethics Committee.

Results: There were 8,617 admissions, of which 3,595 involved a cardiovascular diagnosis. The mean age was 62 years, with a predominance of male patients (60.9%), and mortality ranged from 5.2% to 13.7%. The cohort presented a low-risk Charlson Comorbidity Index (1.2), a pre-frail Modified Frailty Index (MFI-5) (2.02), and a Simplified Acute Physiology Score (SAPS 3) of 44.33. The average duration of mechanical ventilation was 2 days (SD 2.49), and the mean length of stay was 4 days (SD 4.32).Deep vein thrombosis (DVT) (OR = 3.42; 95%CI = 1.57–7.40; p < 0.001), dialysis-dependent chronic kidney disease (DD-CKD) (OR = 2.95; 95%CI = 1.77–4.42; p < 0.001), and the use of vasopressors (OR = 2.38; 95%CI = 1.93–2.94; p < 0.001) were associated with a higher likelihood of cardiovascular related admission. The use of non-invasive ventilation (NIV) (OR = 0.655; 95%CI = 0.540–0.794; p < 0.001) were associated with reduced probability.

Conclusions: The severity scores indicate an intermediate morbidity and mortality profile, with generally favorable prognoses despite the predominance of older adults. Modifiable clinical factors that protect against progression to cardiovascular complications were identified, such as reducing vasopressor exposure and limiting the need for NIV. Recognizing underlying conditions such DVT and DD-CKD that increase risk is essential for optimal management.

Reference Woolridge S et al. Eur Heart J Acute Cardiovasc Care 2020;9:923–930

P106 Temporal trends in the presentation and management of ST-segment elevation myocardial infarction (STEMI)

E Vanstaen 1 , R Lauwers 1 , A Demolder 2 , R Herman 2 , A Rafajdus 3

1 AZORG, ED, Aalst, Belgium, 2 AZORG, Cardiology, Aalst, Belgium, 3 AZORG, PM Cardio, Aalst, Belgium

Critical Care 2026, 30 (Suppl 1): P106

Introduction: Temporal variations in the presentation rates and treatment of ST-segment elevation myocardial infarction (STEMI) are not fully understood. Identifying patterns of STEMI occurrence may reveal underlying factors altering emergency cardiac care delivery and resource planning.

Methods: We retrospectively analyzed all patients with acute chest pain who underwent cardiac catheterization between January 2023 and December 2024 at a tertiary referral center. Demographics, clinical and procedural characteristics, ECG findings and management metrics were collected. Temporal STEMI incidence was analyzed across days, weeks and months using time-series analyses. Door-to-cathlab time and in-hospital mortality were compared.

Results: Among 562 chest pain patients (mean age 68.2 ± 13.4 years, 69.6% male), 165 patients (29.4%) were diagnosed with STEMI. Distribution throughout the year was non-uniform: peaking in April (late winter, early spring), while the lowest incidence was observed in October (autumn) ( p = 0.003, chi-square goodness-of-fit test). Monthly patterns were consistent across both years ( p = 0.30). Weekly variation revealed peaks on Mondays and Fridays and fewer admissions on weekends ( p = 0.016, chi square goodness-of-fit test). The weekly variation was consistent across all months ( p = 0.329). Median door-to-cathlab time improved from 2023 to 2024 (15.2 h [1.5–45.5] vs. 7.6 h [0.9–22.6], p < 0.001). The shortest median door-to-cathlab time was noted in April (0.4 h [0.3–1.1]), suggesting higher vigilance during clustered presentations though there was no statistical significance ( p = 0.158).

Conclusions: In this single-center registry, STEMI presentations showed seasonal variation, peaking in late winter/early spring and reaching a low in autumn, alongside consistent weekly patterns. Continuous temporal monitoring may support more responsive resource planning in acute cardiac care.

P107 Myocardial infarction in young adults < 45: risk profile and clinical course

G Silva 1 , J Fidelis 1 , M Camargo 1 , H Valente 2 , P Morelhão 3 , CE Bosso 1

1 Universidade do Oeste Paulista UNOESTE, Medical College, Presidente Prudente, Brazil, 2 Universidade Estadual Paulista “Júlio de Mesquita Filho” UNESP, Department Physical Therapy, Presidente Prudente, Brazil, 3 Associação Fundo de Incentivo à Pesquisa AFIP, Institute, São Paulo, Brazil

Critical Care 2026, 30 (Suppl 1): P107

Introduction: The first coronary event has been occurring at progressively younger ages [1]. Yet evidence on the risk factors and clinical outcomes of myocardial infarction (MI) in young adults in Brazil remains limited. Understanding this population is essential due to the long term health and socioeconomic implications of early onset MI. This study evaluated the risk factors and clinical outcomes associated with MI in individuals under 45 years of age.

Methods: We conducted a retrospective cohort study of 1,845 patients. Pathological data were obtained through a systematic review of electronic medical records from the Coronary Intensive Care Unit at the Regional Hospital of Presidente Prudente, São Paulo, Brazil. The study was approved by the institutional Ethics Committee. Logistic regression models were employed to evaluate the associations of interest.

Results: The use of psychoactive substances (OR = 13.36; 95%CI = 1.87–95.62; p = 0.01), alcoholism (OR = 2.28; 95%CI = 1.26–4.14; p = 0.007), smoking (OR = 1.60; 95%CI = 1.12–2.29; p = 0.010) and male sex (OR = 1.55; 95%CI = 1.03–2.38; p = 0.035) were significantly associated with an increased likelihood of MI in young people. Diabetes (OR = 0.27; 95%CI = 0.16–0.45; p < 0.001), hypertension (OR = 0.25; 95%CI = 0.17–0.36; p < 0.001), hypothyroidism (OR = 0.13; 95%CI = 0.02–0.95; p = 0.045), NYHA functional class II-III (OR = 0.32; 95%CI = 0.12–0.87; p = 0.025), and a previous history of MI (OR = 0.49; 95%CI = 0.27–0.88; p = 0.017) were associated with a lower probability of MI in young people. Younger patients had lower odds of requiring a bladder catheter (OR = 0.315; p < 0.001) and mechanical ventilation (OR = 0.401; p = 0.021).

Conclusions: Modifiable lifestyle factors, including smoking, alcohol consumption, and the use of psychoactive substances were associated with MI in young adults. Younger patients also required fewer invasive procedures, indicating a more favorable short-term clinical course.

Reference Gupta A et al. J Am Coll Cardiol 2014;64:337–345

P108 The CAMI score: a new prognostic tool

Y Walha, W Demni, D Hamdi, K Jemai, K Ouerhani, F Mansour, W Bahria, N Nouira

Monji Slim Hospital, Emergency Department, Tunis, Tunisia

Critical Care 2026, 30 (Suppl 1): P108

Introduction: ST-segment elevation myocardial infarction (STEMI) represents a critical diagnostic and therapeutic emergency. Risk stratification is strongly recommended to guide management. The objective was to evaluate the performance of the CAMI-STEMI score in predicting in-hospital mortality as well as the occurrence of major adverse cardiovascular events (MACE) during hospitalization and at 30 days.

Methods: A prospective, observational, and longitudinal study conducted from February 1, 2022, to September 30, 2023, including patients admitted for the management of STEMI. The CAMI-STEMI score was evaluated for predicting in-hospital and 30-day mortality.

Results: During the study period, 163 patients were included. The mean age was 61 ± 13 years, with a gender ratio of 4.6. Hypertension was the main cardiovascular risk factor (41.7%), followed by smoking (40.5%) and diabetes (38%). The primary reperfusion methods were thrombolysis (79 patients) and primary percutaneous coronary intervention (69 patients). In-hospital mortality was 14.1%, in-hospital MACE was 23%, and MACE at 30 days post-discharge was 19%. Univariate analysis of the CAMI-STEMI score showed it to be a predictor of in-hospital mortality, in-hospital MACE, 30-day MACE, and cumulative 30-day mortality, with p values of 0.01, < 0.01, 0.019, and < 0.01, respectively. ROC curve analysis demonstrated that the score was significant for in-hospital mortality, in-hospital MACE, and cumulative 30-day mortality, with AUCs of 0.88, 0.8, and 0.87, respectively.

Conclusions: The CAMI-STEMI score in our study not only predicts in-hospital mortality and early in-hospital MACE but also mortality at 30 days post-episode.

P109 Real-world diagnostic and prognostic performance of an AI-enhanced electrocardiogram for acute myocardial infarction in the emergency department

YJ Seong, SH Lee, EJ Jung, SJ Ryu, YS Cho

Chonnam National University Hospital, Emergency Medicine, Gwangju, South Korea

Critical Care 2026, 30 (Suppl 1): P109

Introduction: Artificial intelligence–based ECG interpretation shows potential for detecting acute myocardial infarction (AMI), but its real-world clinical utility remains unclear. This study evaluated the diagnostic and prognostic performance of an AI-enhanced ECG model in emergency department (ED) patients with suspected AMI.

Methods : The ROMIAE project was a prospective, multicentre cohort study across 18 university hospitals in Korea (March 2022–October 2023). Adults presenting within 24 h of AMI-suggestive symptoms were enrolled. Key predictors included the AI-ECG score, HEART score, GRACE 2.0 score, high-sensitivity troponin, and a physician-derived AMI score. The primary outcome was confirmed AMI during index hospitalization; the secondary outcome was 30-day major adverse cardiovascular events (MACE).

Results: Among 8,493 participants, 1,586 (18.6%) were diagnosed with AMI. AI-ECG demonstrated strong diagnostic performance (AUROC 0.878; 95% CI 0.868–0.888), comparable to the HEART score (0.877) and superior to GRACE 2.0, troponin, and physician assessment. For 30-day MACE prediction, AI-ECG maintained high discrimination (AUROC 0.866; 95% CI 0.856–0.877), similar to the HEART score (0.858). Adding AI-ECG to risk stratification significantly improved classification, yielding a net reclassification index of 19.6% and increasing the C-index to 0.926, compared with the HEART score alone.

Conclusions: In routine, multicentre ED practice, the AI-ECG provided robust diagnostic accuracy for AMI and strong short-term prognostic performance. Its effectiveness matched or exceeded established clinical scores and physician judgment, supporting the value of integrating AI-ECG into AMI assessment and risk stratification.

P110 Non-ST-elevation acute coronary syndrome in the emergency department: predictive factors of acute heart failure

W Saidi, W Bahria, Y Walha, D Wiem, D Hamdi, I Aloui, F Lachtar, N Nouira

Monji Slim Hospital, Emergency Department, Tunis, Tunisia

Critical Care 2026, 30 (Suppl 1): P110

Introduction: Non-ST elevation acute coronary syndromes (NSTE-ACS) represent a major public health issue in Tunisia. They are associated with a significant risk of complications, particularly acute heart failure (AHF), with a high mortality rate. The aim of our study was to determine the predictive factors of AHF in patients admitted to the emergency department (ED) for NSTE-ACS.

Methods: This observational, descriptive, prospective, and single-center study was conducted in the ED of Mongi Slim Hospital over a period of 17 months. We included patients over 18 years old admitted to the ED for NSTE-ACS. Patients with sepsis or hemorrhagic shock were excluded. The primary outcome was the occurrence of short-term (in the ED) and medium-term (at 6 months) AHF.

Results: A total of 245 patients were included in the study. The mean age of the patients was 63 ± 0.54 years, with a range from 27 to 93 years. A male predominance was observed, with a sex ratio of 1.69. Among the patients, 87% had at least one cardiovascular risk factor. AHF was observed in 16% of patients at admission and in 27% of patients at 6 months. In multivariate analysis, the independent predictive factors for short-term AHF were a history of atrial fibrillation, renal failure, CRP ≥ 10 mg/dl, and LVEF < 45%, with ( p = 0.001; adjusted OR = 5.32; 95% CI [1.48–19.18]), ( p = 0.006; adjusted OR = 5.51; 95% CI [1.61–18.76]), and ( p ≤ 0.001; adjusted OR = 4.20; 95% CI [1.61–10.97]), respectively. The independent predictive factors at 6 months were a history of diabetes and treatment with loop diuretics, with ( p = 0.002; adjusted OR = 4.04; 95% CI [1.64–9.98]) and ( p = 0.001; adjusted OR = 6.5; 95% CI [2.39–17.96]), respectively.

Conclusions: These results highlight the importance of early and appropriate management of patients at risk for AHF, especially those with cardiovascular history and unfavorable biological markers, in order to improve their short- and medium-term prognosis.

P112 Prognostic value of the leuko-glycemic index in ST-segment elevation myocardial infraction in the emergency department

D Hamdi, F Sbei, Y Walha, W Demni, W Bahria, N Nouira

Monji Slim Hospital, Emergency Department, Tunis, Tunisia

Critical Care 2026, 30 (Suppl 1): P112

Introduction: The Leuko-Glycemic Index (LGI) is an index that combines white blood cell count and venous blood glucose level. It has been described in the literature as a marker of systemic inflammatory response and as a prognostic factor in myocardial infraction. The aim of this study was to determine the prognostic value of the LGI in ST-Segment Elevation Myocardial infarction (STEMI) in the emergency department.

Methods: This was a prospective analytical study, conducted in the emergency department over a 24-month period, including patients over 18 years old admitted to the emergency department with STEMI. The LGI was measured at admission for all patients.

Results: A total of 168 patients were included. The mean age was 61 ± 13 years, with a male predominance (76%). Hypertension was the most common cardiovascular risk factor (41%), and 37% were known diabetics. The mean LGI in known diabetic and non-diabetic patients was respectively 9579 ± 6297 mg/dL·mm 3 and 6449 ± 6386 mg/dL·mm 3 , ( p = 0.026). The most frequent complication was acute pulmonary edema (12.5%), followed by arrhythmias (11.3%) and cardiogenic shock (9.5%). Patients with arrhythmia had a higher LGI compared to those without arrhythmia (12,899 mg/dL·mm 3 versus 7,258 mg/dL·mm 3 , p < 0.001). The LGI measured at admission was significantly associated with the occurrence of acute pulmonary edema (AUC = 0.724; p = 0.004; 95% CI = [0.58–0.868]), cardiogenic shock (AUC = 0.756; p = 0.016; 95% CI = [0.54–0.97]), and in-hospital mortality (AUC = 0.801; p < 0.001; 95% CI = [0.665–0.936]).

Conclusions : The LGI was associated with the occurrence of complications and mortality in patients with STEMI. The LGI could be used for prognostic assessment. Larger-scale studies with patient follow-up are needed to better determine the prognostic value of the LGI.

P114 How should new-onset atrial fibrillation (NOAF) on critical care be managed at discharge?

H Dial, M Spivey, A Garland, S Thomas, CC Research Team

Royal Cornwall Hospital, Critical Care, Truro, UK

Critical Care 2026, 30 (Suppl 1): P114

Introduction: Atrial fibrillation (AF) is exceedingly common in the critically unwell. Emerging data suggests that NOAF in ICU survivors is associated with poor outcomes. There is increased risk of short and long term complications following NOAF [1]. Individuals who develop NOAF during their ICU admission represent a unique population and there are currently no accepted risk stratification tools to guide follow up.

Methods: Analysis of 561 patients who developed NOAF during their ICU admission from 2015 to 2025. Electrolyte disturbance and the use of vasopressors were recorded. Initiation of anticoagulation at the time of NOAF and whether echocardiography was utilised. We recorded whether NOAF had resolved at the time of discharge and whether NOAF was included in the discharge summary.

Results: Of the 561 patients included in this study, 47% underwent echocardiogram during their inpatient stay. 430 patients survived until discharge. Of these patients, 21% were still in AF on discharge from ICU. 42% had documentation of NOAF in their discharge summary. Interestingly, only 70% of patients still in AF at discharge had NOAF mentioned in their discharge summary.

Conclusions: Follow up after discharge could improve outcomes for these patients. Evidence from this large DGH shows that while AF is a common occurrence during ICU admission, echocardiogram is rarely used in these patients. The minority of patients with NOAF have any documentation after discharge.

Reference Sibley S et al. Intensive Care Med 2025;51:904–16

P116 New-onset atrial fibrillation (NOAF) in ICU patients: An audit of clinical characteristics, management strategies, and outcome in a large DGH critical care unit

SG Thomas, H Dial, M Spivey, A Garland, AF Trainee Collaboration Group

Royal Cornwall Hospital NHS trusts, Critical Care Department, Truro, UK

Critical Care 2026, 30 (Suppl 1): P116

Introduction: NOAF is common in critically ill patients and associated with increased morbidity and mortality [1]. There is no consensus for management strategies of ICU acquired NOAF.

Methods: Using Philips ICCA, patients who developed NOAF during their ICU admission from 2015 to 2025 were identified. Records were examined for pre-AF electrolytes, vasopressor requirements, management strategies, and discharge status.

Results: Incidence of NOAF was 6.2%. Among 557 patients who developed NOAF, 341 (61.2%) converted to sinus rhythm at discharge, 17.2% remained in AF & 21.5% died. Pre-AF electrolyte levels (K + : 4.26 ± 0.66 mmol/L; Mg2 + : 0.94 ± 0.26 mmol/L) showed no significant association with AF at discharge. Pre-AF noradrenaline requirements were strongly associated with in-hospital mortality. Patients on noradrenaline (33.9%) had higher mortality (33.3%) compared to those not on vasopressors (15.6%, risk ratio 2.14). The Table demonstrates management intervention, success rate and associated mortality.

Conclusions: Pre-AF electrolyte levels do not independently predict AF persistence at discharge. Increased vasopressor dosing identified a critically ill subgroup with elevated mortality.There was no difference in rhythm control between amiodarone or β-blockade, but DCCV was the most effective, yet rarely used.

Reference Sibley S et al. Intensive Care Med 2025;51:904–16

Table (abstract P116) Medical intervention, success rate and associated mortality

P117 Effect of landiolol compared to amiodarone in treatment of supraventricular cardiac arrhythmias in septic shock patients

A Hordyna 1 , M Domagala 2 , M Szukala 1 , D Siwicka 1 , W Dabrowski 3

1 Medical University of Lublin, Lublin, Poland, 2 Medical Division of Jan Kochanowski University, Department of Anaesthesiology and Intensive Therapy, Kielce, Poland, 3 Medical University of Lublin, Anaesthesiology and Intensive Therapy, Lublin, Poland

Critical Care 2026, 30 (Suppl 1): P117

Introduction: Supraventricular cardiac arrhythmias (SA) in septic shock patients (SS) can lead to haemodynamic instability and hypotension, requiring increased doses of vasopressors. Landiolol, the ultra-selective β1 blocker, or amiodarone are commonly used to treat such disorders. Some studies documented a beneficial effect of landiolol in critically ill patients [1,2]. The aim of this study was to analyse the effects of landiolol and amiodarone on the dose of vasopressors, some haemodynamic variables and time required to restore normocardia.

Methods: Adult patients treated with landiolol or amiodarone for SA following SS were studied. Patients with a previous history of recurrent SA were excluded. Haemodynamic variables including: heart rate (HR), cardiac index (CI) and stroke volume variation (SVV) were measured using EV1000 platform (Edwards, USA). Continuous norepinephrine infusion was used to correct the mean blood pressure and systemic vascular resistance index. Both landiolol and amiodarone were administered continuously: Landiolol at 20 μg/kg/min and amiodarone at 7 μg/kg/min (approximately 600 mg/day). The effects of landiolol and amiodarone were analysed within 96 h.

Results: 120 patients were included. Five were excluded due to a lack of data or withdrew their agreement. Finally, 60 patients were treated with landiolol and 55 with amiodarone. The mean time to restoration of normocardia was 12 ± 5.5 h in patients treated with landiolol and 42 ± 16 h in patients treated with amiodarone. Landiolol corrected CI and SVV within 24 h, whereas amiodarone did not affect either parameter for 72 h. Treatment with landiolol allowed for a reduction a dose of norepinephrine during the studied period (Figure).

Conclusions: Landiolol restored normal heart rhythm significantly faster than amiodarone. Use of Landiolol improves cardiac output, probably by SVV correction.

References Dabrowski W et al. Int Heart J 2020;61:384 Ditali V et al. ESC Heart Fail 2022;9:766

Figure (abstract P117) Changes in heart rate (HR), cardiac index (CI), stroke volume variation (SVV) and dose of norepinephrine in septic shock patients treated with landiolol or amiodarone due to supraventricular tachyarrhythmias. * p < 0.05, ** p < 0.01 and *** p < 0.001—differences with baseline value (Wilcoxon test)

P118 Early versus late beta-blocker initiation in critically ill patients: a retrospective observational study

WL Song 1 , WN Zhu 1 , XX Ma 1 , YL Lu 2 , JF Wu 1 , XD Guan 1 , X Si 1 , R Shi 1

1 The First Affiliated Hospital of Sun Yatsen University, Critical Care Medicine, Guang Zhou, China, 2 Longgang Central Hospital, Critical Care Medicine, Shen Zhen, China

Critical Care 2026, 30 (Suppl 1): P118

Introduction: The optimal timing for initiating beta-blocker therapy in critically ill patients remains unclear. This study investigated the impact of early versus late administration of short-acting beta-blockers on heart rate control, hemodynamic stability, organ support duration, and clinical outcomes.

Methods: In this single-center, retrospective observational study, ICU patients who received beta-blockers between June 2016 and December 2022 were analyzed. Propensity score matching (PSM) was used to balance baseline characteristics between groups. Early initiation was defined as within 24 h of ICU admission; late initiation occurred thereafter. Heart rate (HR) was assessed using generalized estimating equations. Kaplan–Meier and Cox regression analyses were employed to evaluate 28-day mortality. The primary outcome was HR control; secondary outcomes included hemodynamic parameters, ICU and hospital length of stay (ICULOS, HLOS), vasopressor duration, and mortality.

Results: Of 3,963 screened patients, 466 were included after PSM (233 per group). Median BB initiation time was 10 h (early) vs 45.7 h (late), using a 24h cutoff. Early BB use significantly reduced HR (− 5.9 bpm, p < 0.01; Figure, panel a), ICU-LOS and HLOS (21 vs 28 days, p < 0.001), without affecting mortality (Figure, panel d). Despite higher initial NE doses, vasopressors were weaned faster in the early group (32 vs 46 h, p = 0.024; Figure, panel c). In subgroup analyses, early BB shortened ICU-LOS/HLOS in non-septic patients (21 vs 29 days, p < 0.001) and ventilation time in septic patients (56 vs 126 h, p = 0.046). Among those on NE before BB, early use further improved HR (− 8.9 bpm, p < 0.001; Figure, panel e) and reduced vasopressor duration (82 vs 131h, p = 0.015).

Conclusions: Early initiation of beta-blockers in ICU patients was associated with better heart rate control, reduced ICU/hospital stay, and faster vasopressor weaning—particularly among non-septic patients and those receiving early vasopressor support.

Figure (abstract P118) Efficacy and safety of early (< 24 h, red) vs late (≥ 24 h, blue) BB use in critically ill patients. a. HR control; b. effect on MAP; c. NE requirement d. survival (log-rank p = 0.162); e. HR in patients on NE before BB; f. HR in sepsis subgroup

P119 Some factors affecting the ineffective treatment of cardiac arrhythmias with landiolol in septic shock patients

W Dabrowski 1 , M Domagala 2 , M Szukala 1 , D Siwicka 1

1 Medical University of Lublin, Anaesthesiology and Intensive Therapy, Lublin, Poland, 2 Medical Division of Jan Kochanowski University of Kielce, Department of Anaesthesiology and Intensive Therapy, Kielce, Poland

Critical Care 2026, 30 (Suppl 1): P119

Introduction: Supraventricular arrhythmias (SA) are frequently noted in critically ill septic shock (SS) patients. Landiolol, the ultra-selective β1 blocker, is used to treat SA. However, the Landi-SEP study challenged its efficacy in SS patients [1]. SS causes electrolyte disorders and associated inflammation predispose to SA [2,3]. Therefore, disorders in blood magnesium concentration and massive inflammatory response can affect landiolol efficacy. The aim of this study was to analyze the relationship between landiolol efficacy, degree of inflammation, and plasma ionized magnesium (iMg) concentration in SS.

Methods: Adult patients treated for SA following SS were studied. Patients with a previous history of recurrent SA were excluded. PCT, CRP, IL-6 concentrations, and neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios reflected the level of inflammation. A blood sample was collected just before landiolol treatment. Landiolol was administered continuously at the dose of 20 μg/kg/min. The effect of landiolol was analysed within 24 h.

Results: 73 patients were included. Treatment with landiolol was ineffective in 13 patients (17.8%). iMg was lower, and IL-6 and PCT were higher in patients treated with landiolol unsuccessfully (iMg: 0.77 ± 0.21 vs. 0.54 ± 0.22 mmol/L, IL-6: 2959.2 ± 1378.2 vs. 1591.7 ± 2033.1 pg/mL, PCT: 23.9 ± 17 vs. 17 ± 16.8 ng/mL) (Figure). Multivariate analysis showed that low iMg and high IL-6 concentrations were associated with ineffective treatment with landiolol ( p < 0.001 and p < 0.05, respectively).

Conclusions: An inflammatory response accompanied by low iMg reduces the effectiveness of landiolol. Low iMg concentrations appear to be the most critical factor affecting landiolol efficacy in septic shock patients.

References Rehberg S et al. Intensive Care Med 2024;50:1622 Safabakhsh M et al. Clin Nutr 2024;43:1299 Armbruster AL et al. Pharmacotherapy 2022;42:250

Figure (abstract P119) Ionised magnesium and interleukin-6 in patients responding (green column) and not responding to treatment with landiolol

P120 Effects of preoperative antiarrhythmic drugs in heart recipients on the occurrence of primary graft dysfunction

G Thery 1 , K Ouellette 2 , Y Lamarche 2 , A Ducharme 2 , G Giraldeau 2 , MC Parent 2 , M Tremblay-Gravel 2 , J Boulet 2 , PE Noly 2

1. Reims University Hospital, Intensive Care Unit, Reims CEDEX, France, 2 Montreal Heart Institute, Montreal, Canada

Critical Care 2026, 30 (Suppl 1): P120

Introduction: The use of medications—especially antiarrythmic drugs administered to the recipient before heart transplantation (HT)—and their association with primary graft dysfunction (PGD) is a matter of concern [1]. In particular, amiodarone may exert negative chronotropic and inotropic effects on the cardiac transplant. Therefore, we sought to investigate the association between pre-transplant antiarrythmic therapy in patients with end-stage heart failure undergoing HT and the incidence of PGD.

Methods: Retrospective, monocentric cohort study, including all primary HT in adult patients between 2010 and 2024 at the Montreal Heart Institute (Québec, CA). Exclusion criteria were multiorgan transplantations and re-transplantation. Inverse probability weights were estimated as the inverse of patients’ estimated probability of developing a PGD. In the propensity score models, the group (absence of PGD or presence of PGD) was the dependent variable, and all confounders were independent variables.

Results: We included 194 patients. One hundred and thirty-six were male (70%), with a mean age of 50.2 years-old and mostly transplanted for a dilated cardiomyopathy (44.8%). Among them, 69 experienced mild to severe PGD with an increased risk of in-hospital mortality (20.3% vs 4.8%, p = 0.002). Ninety-two patients received amiodarone in the 48 h before HT. Preoperative amiodarone was associated with an increased risk of developing PGD (odds ratio (OR) = 3.30 [1.00–10.89], p = 0.049). Amiodarone associated with one beta-blocker or two anti-arrythmic medications was also associated with a risk of PGD (respectively OR = 2.82 (1.46–5.45), p = 0.002, and OR = 2.37 (1.26–4.46), p = 0.007]. The adjusted probability per group of PGD occurrence are represented on the Figure.

Conclusions: Pre-HT use of amiodarone is significantly associated with PGD, whether it is associated with another antiarrhythmic medication or not.

Reference Buchan TA et al. J Heart Lung Transplant 2021:40:642–651

Figure (abstract P120) Adjusted probability per group of PGD occurrence (with 95% CI) 0: No amiodarone, 1: amiodarone only; 2: Amiodarone associated with one betablocker; 3: Amiodarone associated with at least 2 antiarrythmic drugs

P121 Comparison of esmolol versus landiolol on mortality in adult patients with sepsis: a systematic review and network meta-analysis

ZY Tang 1 , Q Sun 2 , J.Y Xu 2 , Y Yang 2 , F Peng 2

1 Southeast University, Department of Critical Care Medicine, Nanjing, China, 2 Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China

Critical Care 2026, 30 (Suppl 1): P121

Introduction: The clinical efficacy of short-acting β-blockers in the management of sepsis remains uncertain. In particular, the comparative effects of two commonly used agents—esmolol and landiolol—have not been clearly established. This network meta-analysis aims to systematically evaluate and compare the effects of esmolol, landiolol and standard of care (SOC) on mortality in patients with sepsis.

Methods: A systematic search of PubMed, Web of Science, Embase, MEDLINE, CENTRAL, ClinicalTrials.gov, preprints and citation searching was conducted before April 15, 2025 (CRD420251033640). A network meta-analysis based on Bayesian (R v4.4.3) and frequentist approaches (Stata v18.0).

Results: A total of 1,165 records were identified through searches of five databases, registries and relevant references up to April 15, 2025. Ten studies involving 1,035 patients were included, after screening and eligibility assessment. Compared to esmolol, landiolol was associated with increased 28-day mortality (RR, 1.57; 95% CI, 1.08–2.30; low certainty) and higher norepinephrine requirements (MD, 0.17 μg/kg/min; 95% CI, 0.02–0.32; low certainty) (Figure). Esmolol significantly reduced 28-day mortality (RR, 0.69; 95% CI, 0.56–0.85; moderate certainty) and 24-h heart rate (MD, –16.92 bpm; 95% CI, –23.49 to –10.36; moderate certainty) compared to SOC. In contrast, landiolol increased norepinephrine use compared to SOC (MD, 0.09 μg/kg/min; 95% CI, 0.01–0.18; moderate certainty).

Conclusions: Moderate to very low certainty evidence suggests that, compared with SOC and landiolol, esmolol may reduce sepsis mortality while maintaining hemodynamic stability without increasing norepinephrine requirements. However, landiolol’s effect remains uncertain. Esmolol indicates potential clinical advantages over landiolol, but direct comparative trials are needed to confirm these results.

Figure (abstract P121) Forest plot results for the outcomes

P122 Improvement in cardiovascular performance with landiolol infusion in cardiogenic shock patients with tachyarrhythmias

G Paissan, M Tosi, S Finetto, M Pasetto, L Peluso, M Ceola Graziadei, A Russo, L Gottin

Hospital and University Trust of Verona, Cardiothoracic and Vascular Intensive Care Unit, Verona, Italy

Critical Care 2026, 30 (Suppl 1): P122

Introduction: Atrial tachyarrhythmias often coexist with worsening heart failure (HF) and can precipitate cardiogenic shock (CS). Adressing rate, rhythm and synchrony is meant to improve the hemodynamic profile. Landiolol, a short-acting β1-superselective blocker, is guideline-recommended for rhythm and rate control of atrial fibrillation (AF) and has demonstrated effectiveness in HF or CS patients. Cardiac power output (CPO) represents the cardiovascular system energy output per unit time.

Methods: Prospective observational single-center cohort study, started 03/25. Adult patients with acute HF/CS and tachyarrhythmias. Hemodynamic profile evaluation before (T0), at 1 h (T1) and 6 h (T2) after landiolol infusion start; pulse-contour monitoring and echocardiography.

Results: In this ongoing study we enrolled 7 patients treated with landiolol for CS due to or aggravated by AF; median age was 68 [57–72] years. Four patients were cardiac surgery cases, 3 were CS evolved from secondary cardiomyopathies. Two patients died in the ICU and another 1 in hospital (all were withdrawal of life support therapies); 4 were discharged home. Five cases were new onset AF. In 3 patients (43%) landiolol was effective in restoring sinus rhythm; 2 of 5 that remained in AF already had permanent AF. CPO improved from a median 0.6 [0.3–0.7] W before landiolol infusion to 0.7 [0.5–0.8] W at 1 h and 0.7 [0.6–1.0] W at 6 h, in a statistically significant manner ( p = 0.006, Friedman test); effect size (Kendall’s W) of 0.7 (Figure). Considering RAP in the CPO computation, median increases were from a starting median 0.5 [0.2–0.5] W to 0.5 [0.4–0.7] W at 1 h and to 0.6 [0.5–0.9] W at 6 h ( p = 0.006); effect size (Kendall’s W) of 0.7. CI improved from median 1.9 [1.4–2.2] L/min/m 2 to 2.0 [1.9–2.9] L/min/m2 at 1 h and to 2.2 [1.9–3.1] L/min/m 2 at 6 h.

Conclusions: These preliminary data show that landiolol was effective in ameliorating cardiac mechanic and energetic performance in CS with AF.

Figure (abstract P122) Upper panel: box plots and patients’ line plot showing improvement over time of CPO (Friedman test). T0 = before landiolol start; T1 = at 1 h; T2 = at 6 h. Lower panel: box plots and patients’ line plot showing improvement over time of CPORAP (Friedman test). T0 = before landiolol start; T1 = at 1 h; T2 = at 6 h

P123 AI-driven echocardiographic model for early identification of stress cardiomyopathy

J Ryu 1 , C Harris 1 , C Zhang 1 , R Stevens 2

1 Johns Hopkins University, Whiting School of Engineering, Baltimore, USA, 2 Johns Hopkins University School of Medicine, Department of Anesthesiology and Critical Care Medicine, Baltimore, USA

Critical Care 2026, 30 (Suppl 1): P123

Introduction: This study aimed to develop a view-agnostic, multimodal deep learning model using echocardiography and clinical features to differentiate stress cardiomyopathy (SCM) from acute myocardial infarction (AMI), addressing the limitations of prior work restricted to apical views and lacking EHR integration. SCM closely resembles AMI in presentation, leading to frequent misdiagnoses and inaccurate treatment decisions [1,2].

Methods: Within the MIMIC-IV echocardiography dataset, 33 SCM and 561 AMI patients were identified. A ResNet-18 model with attention generated 512-dimensional embeddings from all available views. Three XGBoost classifiers were trained: an Echo model using video embeddings, an EHR model using 45 clinical variables, and a Fusion model combining both. Five-fold cross-validation was performed, and metrics are reported as mean ± standard deviation.

Results: The Echo model achieved an AUROC of 0.73 ± 0.03 and AUPRC of 0.27 ± 0.07, outperforming the baseline AUPRC of 0.06. The Fusion model showed the highest performance (AUROC 0.78 ± 0.03, AUPRC 0.25 ± 0.04), while the EHR model also provided discriminative value (AUROC 0.63 ± 0.04, AUPRC 0.14 ± 0.06).

Conclusions: Using all echocardiographic views, not only apical views, enabled robust SCM identification even from short, non-standardized clips. This is important as real-world echocardiograms vary widely in view type, quality, and length. The strong performance of the Echo model highlights that echocardiography alone carries a distinct diagnostic signature for early SCM detection.

References Ramaraj R et al. Postgrad Med J 2007;83:543–546 Meng LP et al. World J Clin Cases 2022;10:2616–2621

P124 Invasive hemodynamic monitoring guided resuscitation improves survival in shock: a systematic review and meta-analysis.

L Nagy 1 , C Turan 1 , D Laczkó 2 , PR Tóth 1 , L Légár 3 , B Danisan 3 , Z Sipos 3 , P Hegyi 3 , Z Molnár 1 , L Zubek 1

1 Semmelweis University, Department of Anesthesiology and Intensive Therapy, Budapest, Hungary, 2 Semmelweis University, Department of Interventional Radiology, Heart and Vascular Centre, Budapest, Hungary, 3 Semmelweis University, Centre for Translational Medicine, Budapest, Hungary

Critical Care 2026, 30 (Suppl 1): P124

Introduction: Mortality in shock may reach 60%, hence, immediate, adequate resuscitation has a crucial role in improving outcomes. Detailed hemodynamic monitoring is desirable, but evidence concerning its outcome benefits is limited. Therefore, this study aimed to compare advanced hemodynamic monitoring (AHDM) guided to conventional treatment on outcomes in shock.

Methods: A systematic search was performed on PubMed, EMBASE, and Cochrane Library until November 9, 2024. RCTs, non-randomised and observational studies about adult shock patients were eligible. Main outcomes were in-hospital and 30-day mortality, with length of stay, need and duration of organ support, and amount of fluid administered as secondary outcomes. Meta-analyses were performed using a random-effects model, with assessment of heterogeneity and risk of bias.

Results: 34 studies, with seven RCTs and a total of 636,441 shock patients comparing AHDM versus conventional monitoring, were analysed. The use of any type of AHDM in any type of shock was associated with a significantly lower in-hospital mortality (OR: 0.66; 95% CI: [0.48;0.91]; p = 0.014), especially in cardiogenic shock patients, managed by pulmonary artery catheter-guided therapy (OR: 0.68; CI: [0.60;0.78]; p < 0.001) (Figure). This contrasts with the significantly higher odds of need for organ support treatment, including inotropes (OR: 2.32; CI: [1.29;4.19]; p = 0.002), vasopressors (OR: 1.46; CI: [1.05;2.04]; p = 0.030), mechanical circulatory support (OR: 2.85; CI: [1.62;5.02]; p = 0.002), renal replacement therapy or mechanical ventilation, while the the duration of mechanical ventilation was shorter.

Conclusions: AHDM use is associated with a significant reduction in mortality among shock patients, with the greatest benefit observed in cardiogenic shock. The higher need for organ support reflects a more precise identification of the underlying cause and a more targeted therapeutic approach, enabled by AHDM, which improves outcomes. These results support its early application in severe or refractory cases.

Figure (abstract P124) In-hospital mortality. PSM: propensity score matched patients; W: weighted data

P125 Prognostic performance of lactate, ΔPv–aCO₂ and central ScvO₂ for 28-day mortality in septic and cardiogenic shock: a retrospective comparative analysis

M Benlabed 1 , S Benlabed 2 , R Gaudy 3 , V Sobkova 4 , R Mehyaoui 5 , J Malaska 6

1 Lille University, Anesthesiology and Intensive Care, Lille, France, 2 Free University of Brussels, Brussels, Belgium, 3 Lille University, Lille, France, 4 University of Prague, Prague, Czech Republic, 5 Algiers University, Algiers, Algeria, 6 Masaryk University, Brno, Czech Republic

Critical Care 2026, 30 (Suppl 1): P125

Introduction: Lactate, ΔPv–aCO₂, and central ScvO₂ are routinely used to assess tissue perfusion in circulatory shock, yet their comparative prognostic performance remains debated. We aimed to evaluate and compare the ability of these three markers, measured at ICU admission (T0) and 6 h later (T6h), to predict 28-day mortality in septic and cardiogenic shock.

Methods: This retrospective study included 300 adult ICU patients, 150 with septic shock and 150 with cardiogenic shock (2018–2024). Lactate, ΔPv–aCO₂, and ScvO₂ were systematically collected at T0 and T6h. The primary endpoint was 28-day mortality. ROC curves were generated using DeLong’s method. Pronostic performance for predicting 28 day mortality used AUC values for comparison of biomarkers within each shock phenotype.

Results: Overall 28-day mortality was 34% in septic shock (51/150) and 42% in cardiogenic shock (63/150), consistent with European cohorts. In septic shock, lactate [1] demonstrated the best prognostic accuracy (AUC 0.90), outperforming ΔPv–aCO₂ (AUC 0.83) and ScvO₂ (AUC 0.78) (Figure). In cardiogenic shock, lactate again showed superior prognostic performance (AUC 0.94) vs ΔPv–aCO₂ (AUC 0.89) and ScvO₂ (AUC 0.82). Across both shock phenotypes, T6h values moderately improved AUCs compared with T0, especially for ΔPv–aCO₂, supporting a dynamic assessment strategy.

Conclusions: In this large retrospective cohort including 300 patients, lactate consistently outperformed ΔPv–aCO₂ and ScvO₂ for predicting 28-day mortality in both septic and cardiogenic shock. ΔPv–aCO₂ provided intermediate prognostic value, whereas ScvO₂ showed limited discrimination. Measuring these biomarkers at T0 and at 6 h enhances prognostic accuracy, reinforcing their role in early hemodynamic assessment. These findings support lactate [1,2] as the most robust single perfusion marker across shock phenotypes and provide a strong rationale for prospective validation.

References Marty P et al. Ann Intensive Care 2013;3:3 Klemm G et al. J Clin Med 2024;13:1932

Figure (abstract P125) Prognostic accuracy for 28 day mortality of lactate, ΔPv–aCO₂, and ScvO₂

P127 Invasive cannula placement: impact on training opportunities of an advanced critical care practitioner (ACCP) and subsequent independent service and teaching provision

M Vaz Guedes 1 , R Heij 1 , E Young 2 , M Osborne 1 , J Oliveira 1 , H Santos 1 , P Young 1

1 QEH, Critical Care, Kings Lynn, UK, 2 University of Cambridge, Department of Mathematical Statistics, Cambridge, UK

Critical Care 2026, 30 (Suppl 1): P127

Introduction: Advanced critical care practitioners (ACCPs) require supervised experience in central venous catheterisation and arterial line placement. During this initial period, ACCPs may appear to reduce procedural opportunities for resident doctors. Once competent, however, they provide independent service and deliver procedural teaching, potentially generating a substantial net gain. The objective of this study is to quantify the invasive line training required for a new ACCP, describe the timeline to independent practice, and estimate the long-term service and teaching benefit relative to the initial supervised training period.

Methods: Prospectively collected data were analysed for a newly appointed ACCP from September 2022 to September 2025 in a mixed medical-surgical ICU. Cumulative counts were recorded for supervised procedures during training, independent procedures after competency sign-off, and episodes where the ACCP taught resident doctors. A linear 30-year projection estimated long-term impact.

Results: The ACCP required 38 supervised invasive procedures for competency. Over the subsequent three years, the ACCP performed 92 independent procedures and provided 58 supervised teaching episodes (Figure). This represents a + 240% service benefit and + 150% teaching benefit relative to the training "cost", achieving an early approximately + 395% net gain. A 30-year projection indicates that training procedures would constitute less than 1% of lifetime procedural activity, with approximately 61% representing independent service and 38% supervised teaching.

Conclusions: Training an ACCP in invasive cannulation requires a modest supervised procedural investment, yet independent practice begins early and rapidly generates a substantial surplus of both service provision and resident teaching opportunities. These findings support ACCP development as an efficient strategy for sustaining invasive procedural capacity and enhancing ICU training.

Figure (abstract P127) Timeline for ACCP training requirement, leading to independent practice and provision of teaching

P129 SCORED: ScvO₂-centered optimisation of red blood cell transfusions – protocol of a randomised controlled trial

N Kiss, C Turan, DM Karim, M Papp, L Zubek, Z Molnar

Semmelweis University, Department of Anaesthesiology and Intensive Therapy, Budapest, Hungary

Critical Care 2026, 30 (Suppl 1): P129

Introduction: In our multicentre randomised controlled trial, we aim to investigate the efficacy and safety of central venous saturation (ScvO 2 )-guided transfusion triggers versus transfusion based on clinicians’ decisions in the critically ill. International guidelines recommend restrictive transfusion policies based on haemoglobin (Hb) levels; however, evidence regarding physiological transfusion triggers is lacking [1,2].

Methods: In Hungarian medical and surgical ICUs, adults who are haemodynamically and respiratorily stable with a Hb level between 7 g/dl and 9 g/dl will be randomised in a 1:1 ratio. In the treatment arm, 1 unit of red blood cells (RBC) will be transfused if the ScvO 2 is below 70%. Additional units will be given until the central venous saturation reaches 70%. In the control arm, the decision to transfuse will be made based on clinicians’ judgement, without knowledge of ScvO 2 . After enrolment, patients will continue to receive RBC transfusions in their respective arms. A two-sided overall significance level of 5% and 80% power were targeted to detect a mean difference of 1 RBC unit between the two treatment groups. The planned sample size resulted in 619 patients in total. An unblinded interim analysis is planned after 30% of patients (~ 186) have been enrolled.

Results: Our primary outcome will be the number of units of red blood cells transfused. The secondary outcome will be the change in central venous saturation. As exploratory outcomes, we will report on mechanical ventilation duration and vasopressor requirements, changes in the carbon dioxide gap, incidence of end-organ failure, infectious complications, renal replacement therapy, organ support-free days, and ICU and hospital lengths of stay.

Conclusions: We aim to demonstrate that incorporating a physiological transfusion trigger is an effective and safe approach to reduce the overall transfusion rate in the critically ill.

References Raasveld SJ et al. JAMA 2023;330:1852–1861 Lu K et al. Transfus Med 2022;32:375–382

P131 Impact of red blood cell transfusion on oxygen metabolism in patients receiving venovenous extracorporeal membrane oxygenation

L Liu, J Wu, S Chen, H Xue, D Hu, Y Zhu, Y Tang, A Liu, H Qiu, S Liu

Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China

Critical Care 2026, 30 (Suppl 1): P131

Introduction: This study evaluated the effects of red blood cell (RBC) transfusion strategies on oxygen metabolism and clinical outcomes in venovenous extracorporeal membrane oxygenation (VV ECMO) patients, addressing controversies on hemoglobin thresholds, oxygen delivery, and tissue utilization.

Methods: A retrospective study included adults on VV ECMO at Zhongda Hospital (Jan 2017–Mar 2025). Demographic, clinical, ECMO-specific, and transfusion parameters were analyzed. Primary endpoints were pre/post-transfusion oxygen metabolism changes; secondary endpoints included hemoglobin trends, transfusion rates, and clinical outcomes. Spearman’s correlation assessed hemoglobin–oxygen metabolism relationships. Mortality was analyzed via Kaplan–Meier methods and covariate-adjusted models; locally weighted scatterplot smoothing regression explored nonlinear hemoglobin–mortality associations.

Results: Among 115 patients, 76.5% received ≥ 1 RBC transfusion within 2 weeks of ECMO initiation. Transfused patients had higher sequential organ failure assessment scores ( p = 0.037) but similar demographics/diagnoses. Median transfusion volume was 1200 mL, with no association to blood type or survival ( 85.2% vs. 88.6%, p = 0.886). Transfusion increased systemic oxygen delivery (pre 588.13 vs. post 689.53 mL/min/m 2 , p < 0.001) without improving oxygen consumption, oxygen extraction ratio, central venous oxygen saturation or lactate levels. Post-transfusion ECMO blood flow and oxygen concentration reductions were feasible without compromising stability. Survival did not differ between transfused and non-transfused groups (log-rank p = 0.37), and pre-transfusion hemoglobin concentration below 7 g/dL was associated with higher mortality risk.

Conclusions : RBC transfusion improves systemic oxygen delivery but not tissue oxygen utilization or survival in VV ECMO patients with hemoglobin > 7 g/dL. Restrictive transfusion strategies appear safe in non-severe anemia, though critical thresholds for tissue hypoxia warrant further investigation.

P132 An untargeted exploratory metabolomic analysis in severe trauma patients: the potential role of transfusion

Y Louraoui 1 , A Bagul 1 , N Kseibati 1 , C Chollet 2 , M Werner 1 , N Libert 1 , J Duranteau 1 , F Castelli 2 , A Harrois 1 , A Huertas 3

1 Paris-Saclay University DYNAMIC Lab, Le Kremlin-Bicêtre, France, 2 Paris-Saclay University MetaboHUB Paris, Gif-sur-Yvette, France, 3 Paris-Saclay University DYNAMIC lab, Medecine, Le Kremlin-Bicêtre, France

Critical Care 2026, 30 (Suppl 1): P132

Introduction: Post-trauma multiorgan failure (MOF) mortality is still very high and the underlying mechanisms are not fully understood. Multiple components from injured tissues, altered systemic responses and resuscitation therapies such as transfusion may contribute to MOF onset and/or progression. Identifying predictive phenotypes may help elucidating the pathophysiological mechanisms of post-trauma MOF after transfusion. This study aims to characterize metabolic signatures linked to transfusion using untargeted metabolomics in patients with severe trauma.

Methods: Untargeted exploratory metabolomic analysis was performed in severe trauma patients (n = 19). Blood samples were collected at admission (H0) and after 24 h (H24) in transfused (n = 10) and in non-transfused patients (n = 9), then processed to isolate plasma for storage. Metabolite profiling employed liquid chromatography coupled with high-resolution mass spectrometry (LC-HRMS) utilizing dual chromatography columns to enhance metabolite detection and separation. Univariate and multivariate statistical approaches were applied to validate results and identify distinct metabolic signatures, ensuring analytical robustness. Wilcoxon test was used with a statistical significance for p < 0.05.

Results: Significant differences in metabolomic profiles were found between H0 and H24 timepoints across the overall cohort. Marked alterations were observed in critical pathways, including mitochondrial function, inflammation and oxidative stress at H24 compared to H0. Interestingly, we found different metabolomic signatures in the two subgroups at H24 (Figure).

Conclusions: The identification of a metabolomic signature associated with transfusion after severe trauma holds significant clinical relevance. Further studies are needed to better understand the pathophysiological role of transfusion in MOF onset and/or progression and are critical for advancing therapeutic strategies to improve clinical outcomes.

Figure (abstract P132) Untargeted metabolomic analysis in post-trauma patients. A: Partial least squares discriminant analysis (PLS-DA) in non-transfused versus transfused patients. B: Heatmap representation in non-transfused versus transfused patients at H24 (24 h post-admission)

P133 Patient blood management based coagulation management for massive postpartum hemorrhage: a randomized controlled pilot trial

AA Perez-Calatayud 1 , K Görlinger 2 , LF Giraldo-Cadavid 3 , J Perez-Uriza 4 , K Aguilar-Vidales 3 , D Torres-Valenzuela 3 , ED Anica-Malagon 1

1 Hospital General de México Dr Eduardo Liceaga, Critical Care, Mexico City, Mexico, 2 University Hospital Essen, Department of Anesthesiology and Intensive Care Medicine, Essen, Germany, 3 Hospital del Niño y la Mujer Dr. Felipe Nuñez Lara, Department of Anesthesiology, Queretaro, Mexico, 4 Faculty of Chemical Sciences Universidad Autónoma de San Luis Potosí, Pharmacology Laboratory, San Luis Potosi, Mexico

Critical Care 2026, 30 (Suppl 1): P133

Introduction: Postpartum hemorrhage (PPH) is the leading cause of maternal morbidity and mortality worldwide, particularly in middle- and low-income countries [1–3].

Methods: In this single-center randomized controlled pilot trial, two coagulation management algorithms for massive PPH were compared: one guided by thromboelastometry using fibrinogen concentrate and prothrombin complex concentrate (ROTEM-FC) versus one guided by standard coagulation tests with blood products (SCT-BP). The primary outcome was the number of allogeneic blood products transfused within 24 h. Secondary outcomes included incidence of ≥ 1, 5, and 10 U RBC transfusion, estimated blood loss, time to bleeding control, ICU and hospital length of stay, coagulopathy, hysterectomy, complications, composite adverse events, and in-hospital mortality.

Results: Of 52 randomized subjects, 17/18 (ROTEM-FC) and 32/34 (SCT-BP) were analyzed. At inclusion, both groups had severe PPH, with mean blood loss of 1,256 mL vs. 1,400 mL, respectively. Compared with SCT-BP, the ROTEM-FC protocol significantly reduced total blood components transfused (median [IQR]: 1 [0–2] vs. 2 [1–4]; p = 0.0040), the need for ≥ 1 unit transfused at 24 h (8/17 [47.1%] vs. 25/32 [78.1%]; p = 0.0316), and time to bleeding control (34.1 [10.0] vs. 76.1 [55.2] min; p = 0.0033) (Table). Composite adverse events were lower in the ROTEM-FC group (2/17 [11.8%] vs. 26/32 [81.3%]; RR 0.1758 [0.0482–0.6412]; p = 0.0085). Relative risk for hysterectomy and ICU admission was 0.5882 [0.2607–11.3274]; p = 0.2013 and 0.7240 [0.4704–1.1142]; p = 0.1420, respectively. ICU and hospital stays were significantly reduced. No mortality was observed.

Conclusions: A thromboelastometry and factor concentrate-based algorithm was more effective than an SCT-BP-guided strategy in controlling massive PPH and reducing transfusion requirements, with a marked decrease in composite adverse events.

References Solomon C et al. Br J Anaesth 2012;109:851- 63 WOMAN Trial Collaborators. Lancet 2017;389:2105–16 Collins PW et al. Br J Anaesth 2017;119:411–21

Table (abstract P133) Study outcomes

P134 Early prophylactic anticoagulation with heparin alleviates short-term mortality in critically ill patients with acute pancreatitis patients: a target trial emulation

X Luo, FR Lin, T Huang, JZ Zhang, AQ Lao, ZF Yang

Sun Yatsen Memorial Hospital, Sun Yatsen University, Intensive Care Unit, Guangzhou, China

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Introduction: Minimal data exist on anticoagulation use and timing of heparin in critically ill patients with acute pancreatitis, and whether early heparin use improves ancreatitis survival remains controversial. We aim to emulate a target trial evaluating the effect of early prophylactic anticoagulation with heparin with severe acute pancreatitis patients.

Methods: This target trial emulation used the MIMIC-IV v3.1 database and included adult ICU patients with severe acute pancreatitis. The exposure was defined as prophylactic heparin initiation within 24 h of ICU admission, with dose–response relationships examined. Primary and secondary outcomes were 28-day and 60-day all-cause mortality, respectively. The primary analysis was conducted using the parametric g-formula. To assess robustness, sensitivity analyses were conducted, including evaluations of delayed initiation and dose–response relationships. To explore heterogeneity, subgroup analyses were performed.

Results: In the emulated trial, early prophylactic anticoagulation was associated with significantly lower mortality. The estimated 28-day mortality was 4.3% with heparin compared with 21.3% without (relative risk [RR], 0.20; 95% CI, 0.04–0.45) (Figure). The 60-day mortality was 6.9% with heparin compared with 33.7% without (RR, 0.21; 95% CI, 0.05–0.45). This survival benefit was most pronounced when heparin was initiated within the first day and at a dose of 15,000 IU. The association was consistent across most prespecified subgroups.

Conclusions: Early prophylactic anticoagulation within 24 h of ICU admission was associated with significantly reduced 28-day and 60-day mortality in patients with severe acute pancreatitis. These findings suggest potential benefits of early anticoagulation in this high-risk population and warrant further prospective validation.

Figure (abstract P134) Estimated 28-day (A) and 60-day (B) potential mortality risk under a treatment strategy that allows heparin sulfate use on the first day versus an intervention that never allows heparin use

P135 Determinants and outcomes of delayed etoposide administration in adult secondary hemophagocytic lymphohistiocytosis

J Schmidt 1 , C Gautier 1 , N Bigé 2 , C Bloch-Queyrat 3 , F Pène 4 , S Gaudry 1

1 Hôpital Avicenne, Intensive Care Unit, Bobigny, France, 2 Institut Gustave Roussy, Intensive Care Unit, Villejuif, France, 3 Hôpital Avicenne, Clinical Research Unit, Bobigny, France, 4 Hôpital Cochin, Intensive Care Unit, Paris, France

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Introduction: Secondary hemophagocytic lymphohistiocytosis (HLH) in adults is a rare but severe hyperinflammatory syndrome often leading to multiorgan failure and ICU admission. Etoposide is recommended in severe forms, yet its real-life use and impact in critically ill adults remain poorly characterized. This study aimed to describe etoposide administration patterns and assess the effect of timing on outcomes.

Methods: We conducted a retrospective bicentric cohort study in two French ICUs (2014–2024). Adults with a first episode of severe secondary HLH, defined by ≥ 5 Henter criteria or H-score > 168 plus ≥ 1 organ failure, were included. Clinical, biological, etiological, and therapeutic variables were collected, with particular focus on etoposide use, reasons for delayed or absent administration, and 30-day survival.

Results: Thirty-three patients were included; 17 (51.5%) received etoposide (Figure). Among patients receiving etoposide, median time from diagnosis to administration was 3 days [1–8]. Main reasons for withholding treatment were moribund presentation (n = 5), sepsis (n = 5), renal failure (n = 2), prioritization of etiological therapy (n = 2), or use of another immunomodulator (n = 1). Among treated patients, 8 received early etoposide (≤ 24 h) and 9 late etoposide (> 24 h). Patients receiving etoposide exhibited more organ failures at admission. No survival difference was observed between etoposide and non-etoposide groups ( p = 0.76), nor between early and late administration ( p = 0.83). Overall ICU mortality was 54.5%.

Conclusions: In this cohort of critically ill adults with secondary HLH, etoposide was administered in only half of cases and often with delay. Diagnostic uncertainty, sepsis, renal dysfunction, and perceived futility were major barriers. No survival benefit was associated with etoposide use or earlier treatment. These findings highlight the challenges of applying current recommendations in ICU practice and the need for prospective studies to define optimal therapeutic strategies in adult HLH.

Figure (abstract P135) Cumulative incidence curve of etoposide exposure (censored at D21)

P136 Elastic-net regression using tromboelastographic and perioperative parameters to predict early haemoglobin and fibrinogen changes after bilateral lung transplantation (BLTx)

E Marcano Millán 1 , M Bueno Bueno 1 , S Muñoz González 1 , C Obando Martínez 1 , G Jiménez Tejera 1 , T Recio 1 , G Siesta López 2 , C Rivas Duarte 3 , G García Carrera 4 , V Sagredo Meneses 1

1 Hospital Universitario de Salamanca, Critical Care Unit, Salamanca, Spain, 2 Hospital Universitario de Salamanca, Respiratory/Pneumology Department, Salamanca, Spain, 3 Hospital Universitario de Salamanca, Thoracic Surgery Department, Salamanca, Spain, 4 Hospital Universitario de Salamanca, Anaesthetics Department, Salamanca, Spain

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Introduction: Major blood loss and coagulopathy remain common after BLTx. Point-of-care viscoelastic testing (POCVT) dynamically assesses clot formation and lysis, enabling early recognition of bleeding risk. We evaluated whether baseline TEG parameters at ICU admission, combined with operative time and intraoperative ECMO duration, predict early postoperative declines in haemoglobin, platelets, fibrinogen, and chest drainage volume.

Methods: Eighteen consecutive bilateral lung transplants performed in 2025 were analysed. Sixteen baseline TEG6s variables were collected at ICU admission, along with operative time and ECMO duration. Outcomes included changes in haemoglobin, platelets, and fibrinogen from 0 to 24 h postoperatively, and chest drainage at 24 h. Predictors were standardised, and elastic-net regression with fivefold cross-validation determined model hyperparameters. Median coefficients and 95% confidence intervals were obtained from 1,000 bootstrap resamples.

Results: Cross-validation selected mild penalisation for the haemoglobin model, identifying ECMO duration, operative time, CK_K, and heparinase alpha angle as predictors. For fibrinogen change, stronger lasso-like penalisation retained ECMO duration, CK_ANG, and CKH_MA as main predictors. Models for platelet change and drainage volume were heavily penalised, with near-zero coefficients. Overall, longer ECMO and operative times, along with TEG-derived clot kinetics and strength measures, were linked to greater haemoglobin decreases and fibrinogen variation, while platelet and drainage predictions were weak (Figure).

Conclusions: Combining baseline TEG parameters with perioperative durations using elastic-net regression could help to identify patients at risk of early hemoglobin and fibrinogen decline after BLTx. ECMO and operative times, along with CK-derived indices, were consistent predictors. These findings suggest that integrating POCVT with surgical variables may guide personalized transfusion strategies, pending confirmation in larger cohorts.

Figure (abstract P136) Elastic-net median coefficients for hemoglobin (panel A) and fibrinogen (panel B) models after lung transplantation. Each bar represents the relative contribution of selected clinical and coagulation parameters, with color gradients indicating the magnitude of coefficients. The hemoglobin model (blue scale) highlights ECMO duration and surgery time as key predictors, while the fibrinogen model (orange scale) emphasizes ECMO duration and CK-derived parameters

P137 Early haemostatic phenotypes after bilateral lung transplantation identified by thromboelastography and unsupervised learning

E Marcano Millán 1 , M Bueno Bueno 1 , N Núñez Blanco 1 , N Albalá Martínez 1 , V Pérez González 2 , M Jiménez López 3 , I Trejo González 4 , S Martín Oliva 1 , M Ochoa Calero 1 , V Sagredo Meneses 1

1 Hospital Universitario de Salamanca, Critical Care Unit, Salamanca, Spain, 2 Hospital Universitario de Salamanca, Respiratory/Pneumology Department, Salamanca, Spain, 3 Hospital Universitario de Salamanca, Thoracic Surgery Department, Salamanca, Spain, 4 Hospital Universitario de Salamanca, Anaesthetics Department, Salamanca, Spain

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Introduction: Postoperative coagulopathy is common after bilateral lung transplantation (BLTx) and contributes to early bleeding and transfusion requirements. Thromboelastography (TEG) provides a dynamic assessment of haemostasis, but its integration with conventional markers using artificial intelligence (AI) remains unexplored. This study aimed to identify early haemostatic phenotypes through principal component analysis (PCA) and unsupervised clustering.

Methods: Eighteen consecutive BLTx patients admitted to the intensive care unit between March and October 2025 were included. TEG parameters (CK/CKH/RT: R,K, Angle, MA), haemoglobin, platelets and fibrinogen were recorded at 0, 6 and 24 h, together with chest-drain output. Variables were standardized (Z-scores) and analysed by PCA to reduce dimensionality. The first two components (explaining 56% of total variance) were entered into a k-means model (k = 2–3). Cluster separation was assessed using the Silhouette index.

Results: The model with k = 2 showed the best performance (Silhouette = 0.38), identifying two distinct phenotypes. Cluster 1 (n = 9) showed lower maximum amplitude (MA; CK_MA 53.6 mm, CKH_MA 54.5 mm) and fibrinogen levels (182 mg/dL at 0 h; 184 mg/dL at 6 h), with a trend toward higher early bleeding (chest drainage 428 mL at 6 h) (Figure). Cluster 0 (n = 9) presented higher MA (CK_MA 60.5 mm, CKH_MA 56.7 mm) and fibrinogen (267 mg/dL and 330 mg/dL at 0 and 6 h) with lower early drainage (365 mL). Total 24-h drainage was similar (~ 1000 mL).

Conclusions: Combining TEG with conventional coagulation tests identified two early haemostatic phenotypes after BLTx. The group with lower MA and fibrinogen showed a hypocoagulable profile associated with greater early bleeding. Despite the small sample, this exploratory approach demonstrates the feasibility of PCA-based clustering to reveal clinically relevant phenotypes and may support individualized transfusion strategies in complex thoracic surgery.

Figure (abstract P137) Summary heatmap of key haemostatic parameters by cluster. The figure displays mean values of selected thromboelastography (TEG) and conventional haemostatic variables for each cluster. Cluster 0 corresponds to a normocoagulable phenotype and Cluster 1 to a hypocoagulable phenotype

P138 Utility of anti-FXa guided enoxaparin dose adjustments in critically ill COVID-19 patients

Z Athanasa 1 , A Dimoula 1 , S Manioudaki 1 , A Sakagianni 2

1 Sismanogleio General Hospital, Athens, Greece, 2 Sismanogleio General Hospital, Intensive Care Unit, Athens, Greece

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Introduction: Critically ill COVID-19 patients are at high risk of thrombotic complications, often requiring intermediate-dose enoxaparin. Anti-FXa activity is measured to guide dosing, but its effectiveness in preventing bleeding or thrombotic events is unclear [1]. This study evaluated the impact of anti-FXa guided dose adjustments in invasively ventilated ICU patients.

Methods: We prospectively studied 100 ICU patients with PCR-confirmed SARS-CoV-2. All received weight-based intermediate-dose enoxaparin, adjusted according to anti-FXa activity after the fourth dose (target 0.3–0.7 IU/mL). Bleeding (ISTH criteria), transfusions, thromboembolic events, and ICU outcomes including mortality, ventilation duration, and ICU stay were recorded. Multivariable regression identified independent predictors of bleeding and ICU mortality.

Results: Dose modifications were required in 32%. Bleeding occurred in 47% (14% major), VTE in 7%. Anti-FXa levels did not differ between bleeding and non-bleeding patients. Multivariable analysis identified CrCl < 60 ml/min as the only independent predictor of bleeding, while bleeding, APACHE II ≥ 15, L/N ratio ≥ 0.07, and MV ≥ 8 days were independently associated with ICU mortality (Table). Patients with bleeding had higher mortality (60% vs 17%), longer ventilation, and ICU stay.

Conclusions: Anti-FXa guided dose adjustments alone may be insufficient to prevent bleeding in critically ill COVID-19 patients receiving intermediate-dose enoxaparin. While systematic monitoring allows dose optimization, bleeding remains frequent, especially in patients with impaired renal function. Clinicians should integrate anti-FXa monitoring with individualized risk assessment to balance thrombotic prevention and hemorrhagic risk.

Reference Jonmarker S et al. Thromb J 2023;21:101

Table (abstract P138) Key outcomes and predictors in ICU COVID-19

P139 Fibrinogen concentrate versus cryoprecipitate for bleeding in cardiac surgery patients stratified by surgical urgency in the phase 3 FIBRES study

J Callum 1 , K Karkouti 2 , C Solomon 3 , S Werner 4 , M Gareis 5 , S Knaub 3

1 Queens University and Kingston Health Sciences Centre, Kingston, Canada, 2 University of Toronto and University Health Network, Toronto, Canada, 3 Octapharma AG, Lachen, Switzerland, 4 Octapharma USA, Paramus, New Jersey, USA, 5 Octapharma Pharmazeutika Produktionsges.m.b.H, Vienna, Austria

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Introduction: This post-hoc analysis explored efficacy of fibrinogen concentrate (FC) vs cryoprecipitate (cryo) for treatment of coagulopathic bleeding related to acquired fibrinogen deficiency in cardiac surgery patients from the Phase 3 FIBRES study, stratified by surgical urgency. FIBRES previously demonstrated non-inferiority of FC vs cryo in the population overall [1].

Methods: FIBRES ( NCT03037424 ) enrolled adult cardiac surgery patients on cardiopulmonary bypass (CPB) requiring fibrinogen replacement for clinically significant bleeding. Patients were randomized (1:1) to receive 4 g FC or 10 U cryo for each order within 24 h post-CPB. Patients were stratified by elective/non-elective surgery status. The primary endpoint was allogeneic blood products (ABP) administered up to 24 h after CPB end. Some patients experienced catastrophic bleeding with high, variable transfusion requirements, likely reflecting severe coagulopathies and requiring surgical re-exploration. To eliminate the disproportional impact of these outliers, an exploratory analysis excluded those receiving ≥ 35 U ABPs within 24 h post-CPB (> 90th percentile).

Results: The primary analysis included 735 patients (N = 372 FC, N = 363 cryo). The majority (N = 466; 63%) underwent elective surgery, with 269 (37%) undergoing non-elective surgery. In patients receiving < 35 U ABPs (N = 658, representing 90% of the primary analysis population), and in all patients undergoing elective surgery, FC was non-inferior and superior to cryo (Figure). Non-inferiority, but not superiority, was also demonstrated in patients undergoing non-elective surgery when excluding those receiving ≥ 35 U ABPs (Figure).

Conclusions: FC was superior to cryo after excluding the 10% most extreme or variable surgical cases and in patients undergoing elective surgery. These results support using FC as the preferred treatment for bleeding in cardiac surgery patients with acquired hypofibrinogenemia.

Reference Callum J et al. JAMA 2019;322:1966–7

Figure (abstract P139) Non-inferiority and superiority of the primary endpoint, transfusion of ABPs during the first 24 h after CPB, in patients stratified by surgical urgency

P140 Four-factor prothrombin complex concentrate is superior to frozen plasma in bleeding adult cardiac surgery patients with coagulopathy—results from a phase 3 study

K Karkouti 1 , J Callum 2 , C Solomon 3 , S Knaub 3 , S Werner 4 , K Tanaka 5 , JH Levy 6

1 University of Toronto and University Health work, Anesthesia and Pain Management, Toronto, Canada, 2 Queen´s University and Kingston Health Sciences Centre, Kingston, Ontario, Canada, 3 Octapharma AG, Lachen, Switzerland, 4 Octapharma USA, Paramus, New Jersey, USA, 5 University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA, 6 Duke University School of Medicine, Durham, North Carolina, USA.

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Introduction: This trial compared the efficacy and safety of four-factor prothrombin complex (PCC; Octaplex/BALFAXAR, Octapharma) with frozen plasma (FP) in cardiac surgery. Cardiac surgery with cardiopulmonary bypass (CPB) is often complicated by coagulopathic bleeding, leading to morbidity and mortality. Although guidelines recommend using either PCC or FP for bleeding management, the mainstay therapy in North America is FP.

Methods: LEX-211 (FARES-II; NCT05523297 ) included patients aged ≥ 18 years undergoing cardiac surgery with CPB. After protamine administration, patients with coagulopathic bleeding and INR ≥ 1.5 were randomized 1:1 to receive PCC (1500 IU if ≤ 60 kg; 2000 IU if > 60 kg) or FP (3 U if ≤ 60 kg; 4 U if > 60 kg). Clinical teams were blinded to group allocation until treatment start. The primary endpoint was hemostatic response (effective if no additional hemostatic interventions were administered from 60 min to 24 h after treatment start). Safety endpoints included 30-day treatment-emergent thromboembolic events (TEEs) and death.

Results: Of 538 enrolled patients at 12 sites in Canada and the US, 420 were randomized, treated, consented, and included in the analysis (PCC = 213; FP = 207). Baseline characteristics were comparable between groups. Effective hemostasis was achieved in 77.9% (n = 166) of PCC vs 60.4% (n = 125) of FP patients (diff. 17.6%; 95% CI 8.7, 26.4; p < 0.001 for superiority). Overall, the mean (95% CI) number of allogeneic blood product units transfused within 24 h post-CPB, excluding intervention FP, was 6.6 (5.7, 7.7) in PCC and 9.3 (8.0, 10.8) in FP patients (ratio 0.71; 95% CI 0.57, 0.88; p = 0.002). Treatment-emergent TEEs and mortality occurred in 8.5% (n = 18) and 3.3% (n = 7) of PCC patients and 7.2% (n = 15) and 3.9% (n = 8) of FP patients, respectively.

Conclusions: In cardiac surgery patients, PCC was more efficacious than FP in controlling coagulopathic bleeding without increasing thromboembolic risk. These results support the use of PCC over FP for bleeding management in cardiac surgery.

P141 Comparison of coagulation profiles between treatment with fibrinogen concentrate and cryoprecipitate in patients undergoing major abdominal surgery

A Roy 1 , N Preston 1 , J Rowley 1 , P Porter 1 , S Stanford 1 , S Aigner 2 , H Boehm 2 , S Abraha 2 , J Schuettrumpf 3 , N Rahe-Meyer 4

1 Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK, 2 Biotest AG, Dreieich, Germany, 3 Grifols, Barcelona, Spain, 4 Clinic for Anesthesiology and Intensive Care Medicine, Franziskus Hospital, Bielefeld, Germany

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Introduction: The AdFIrst trial ( NCT03444324 ) showed that the new human fibrinogen concentrate (FC, BT524, Biotest) was non-inferior to cryoprecipitate (Cryo) for managing severe bleeding in patients undergoing complex surgeries with a lower incidence of thromboembolic events. This subgroup analysis evaluated a preemptive hemostatic strategy using FC vs Cryo to manage severe bleeding in patients undergoing cytoreductive surgery for pseudomyxoma peritonei, referred to abdominal surgery, comparing the changes in coagulation parameters between groups.

Methods: In this prospective, phase 3, randomized, partially blinded, active-controlled trial, adult patients undergoing abdominal surgery were randomized 1:1 to receive FC (4 g) or Cryo (2 pools, 10 units, equivalent to 4g), with additional doses as needed. Change in coagulation markers (thrombin-antithrombin III complex [TAT], prothrombin fragments 1 + 2 [F1 + 2]), were measured intraoperatively (prior to first dose, after 15 min, 90 min post dose, end of surgery) and postoperatively on days 2 through 8. Factor VIII [FVIII] and von Willebrand factor [VWF] were evaluated intraoperatively, and at the end of surgery.

Results: During surgery, all patients showed a hypercoagulable state, indicated by elevated levels of TAT and F1 + 2. Patients treated with Cryo showed higher levels of both markers, at 90 min post-administration and at the end of surgery, indicating enhanced systemic thrombin activation. In contrast, patients receiving FC exhibited comparatively lower TAT and F1 + 2 levels. FVIII and VWF levels remained within physiologically regulated ranges in the FC group, whereas higher levels were observed in the Cryo group at 90 min post dose (Figure). At the end of surgery, no relevant differences were observed between groups.

Conclusions: During major abdominal surgery, the prothrombotic tendency appeared to be more pronounced in patients treated with Cryo, while patients receiving FC demonstrated a more controlled coagulation response.

Figure (abstract P141) Intra- and postoperative changes in (A) prothrombin fragments 1 + 2 (F1 + 2), with a limit of detection of 1200 pmol/L; (B) thrombin-antithrombin complex (TAT), with a limit of detection of 60 µg/L. Intraoperative changes in (C) Factor VIII (FVIII) and (D) von Willebrand factor (VWF) levels by treatment group. Reference ranges were: F1 + 2, 69–229 pmol/L; TAT, 0–4.1 µg/L; FVIII, 50–150%; and VWF 50–200%. Abbreviations: Cryo, cryoprecipitate; FC, human fibrinogen concentrate

P142 Evaluation of the performance of qLabs®Fib at admission in severe trauma patients at risk of bleeding

M Holleville 1 , A Gallet 1 , PA Baron 1 , C Bernard 1 , C Raulet-Bussian 2 , E De Raucourt 2 , E Weiss 1

1 Hôpital Beaujon APHP Nord, Department of Anaesthesiology and Critical Care, Clichy, France, 2 Hôpital Beaujon APHP Nord, Service Hématologie Biologique, Clichy, France

Critical Care 2026, 30 (Suppl 1): P142

Introduction: Post-traumatic coagulopathy remain leading causes of potentially preventable death. Hypofibrinogenemia is associated with greater blood loss and increased transfusion requirements [1]. The qLabs®Fib is a recent point-of-care tool developed to measure fibrinogen concentration (Fg) using a single drop of blood. Validated during postpartum haemorrage [2], no data are available in severe trauma. Our study aims to evaluate the performance of qLabs®Fib at admission of severe trauma patients at risk of bleeding (Score REDFLAG ≥ 2) [3].

Methods: For 20 months, in a level1 French traumacenter, Fg was systematically measured at patients admission with REDFLAG ≥ 2 according to pre-hospital informations, using both the qLabs®Fib and the standard Clauss method. We compared Fg results between both methods. Agreement between methods and diagnostic performance of qLabs®Fib for detecting hypofibrinogenemia were evaluated.

Results: On 73 paired tests, agreement between qLabs®Fib and Clauss fibrinogen assays (Figure) is good: 0.94 (0.84–1.04). Using Clauss < 1.5 g/L as the reference standard, qLabs®Fib < 1.5 g/L achieved a high negative predictive value of 95%, indicating that patients classified as non-hypofibrinogenemic by qLabs®Fib were almost never missed. Sensitivity reached 77%, meaning that most clinically relevant cases of low fibrinogen were correctly detected. Specificity was also strong at 89%, supporting the overall reliability of the assay in ruling out unnecessary interventions. Taken together, these findings suggest that qLabs®Fib provides a reassuring level of safety for frontline screening, with a very low risk of failing to identify patients who require fibrinogen replacement.

Conclusions: In severe trauma patients with massive bleeding risk, the use of qLabs®Fib showed good agreement of Fg results with the Clauss method.

References Richards J et al. Trauma Surg Acute Care Open 2023;8:e000937 Hureau M et al. Thrombosis Update 17 2024;100192 Hamada SR et al. Crit Care 2018;22:113

Figure (abstract P142) Correlation and agreement between qLabsFIB and Clauss fibrinogen measurements after removal of statistical outliers (n = 73). The scatter plot illustrates the linear relationship between both methods, with a fitted regression line corresponding to the model: Clauss = 0.94·qLabsFIB + 0.34. The slope (0.94; 95% CI: 0.84–1.04) and intercept (0.34 g/L; 95% CI: 0.13–0.56) indicate a strong linear association, with an excellent coefficient of determination (R 2 = 0.83)

P143 The effect of recombinant human thrombopoietin on platelet levels in critically ill patients with pneumonia-associated thrombocytopenia: a multicenter, randomized controlled trial

Z Zeng 1 , HU Hu 1 , HL Hou 2 , ZS Zhang 3 , LZ Lin 4 , SY Sun 5 , LEI Huang 6 , ZW Zheng 7

1 Nanfang Hospital, Southern Medical University, Critical Care Medicine, Guangzhou, China, 2 Zhongshan People´s Hospital, Critical Care Medicine, Zhongshan, China, 3 Jiangmen Central Hospital, Critical Care Medicine, Jiangmen, China, 4 Panyu Central Hospital, Guangzhou Medical University, Critical Care Medicine, Guangzhou, China, 5 Yuebei People´s Hospital, Critical Care Medicine, Shaoguan, China, 6 Peking University Shenzhen Hospital, Critical Care Medicine, Shenzhen, China, 7 Zhuhai People´s Hospital, Critical Care Medicine, Zhuhai, China

Critical Care 2026, 30 (Suppl 1): P143

Introduction: Thrombocytopenia is a common and prognostically adverse complication in critically ill patients with pneumonia. Recombinant human thrombopoietin (rhTPO) stimulates endogenous platelet production, but robust prospective evidence supporting its use specifically in ICU patients with pneumonia-associated thrombocytopenia is lacking.

Methods: This multicenter, open-label, randomized controlled trial enrolled 178 patients with pneumonia and thrombocytopenia across 8 ICUs in Guangdong Province, China. Participants were randomized (1:1) to receive subcutaneous rhTPO (15,000 U/day; n = 89) or placebo (n = 89). The primary outcome was time to platelet recovery (defined as platelet count ≥ 100 × 10⁹/L or sustained ≥ 50 × 10⁹/L increase for ≥ 2 days). Secondary outcomes included transfusion requirements, bleeding/thrombotic events, 28-day mortality, and ICU/hospital length of stay (LOS). Analysis followed modified intention-to-treat principles (rhTPO = 77, placebo = 82) (Figure).

Results: Among 159 patients, receiving rhTPO significantly shortened the median time to platelet recovery (6.0d vs 7.0 d, p = 0.032). The rhTPO group exhibited a lower incidence of deep vein thrombosis (DVT) at day 7 (11.6% vs 34.2%; p = 0.003). No significant differences were observed in 28-day mortality (32.5% vs 29.3%; p = 0.79), ICU LOS (10.0 vs 12.0 days; p = 0.48), hospital LOS, or bleeding events. Subgroup analysis revealed a greater reduction in platelet recovery time with rhTPO in patients at high thrombotic risk (5.0 vs 9.0 days to recovery; p = 0.001). Safety profiles were comparable between groups.

Conclusions: rhTPO accelerates platelet recovery and reduces thrombotic complications in critically ill patients with pneumonia-related thrombocytopenia, offering a promising therapeutic alternative with a favorable safety profile.

Figure (abstract P143) Flowchart

P144 Use of erythropoiesis stimulating agents for anemia correction in critically ill lung transplant candidates

S Chaudhary 1 , A Chaudhary 2 , SB Bhusal 2 , AC Chaudhary 2 , P Balasubramanian 2 , PK Guru 2 , MB Baz 2 , K Quiza 2 , R Bag 2

1 Mayo Clinic, Critical Care, Jacksonville, USA, 2 Mayo Clinic, Jacksonville, USA

Critical Care 2026, 30 (Suppl 1): P144

Introduction: Anemia is a common finding among lung transplant candidates. However, whether chronic pre-transplant anemia independently predicts perioperative red blood cell (RBC) transfusion burden is unclear. This study aims to determine the impact of pre-transplant anemia severity and anemia-directed therapy on perioperative RBC transfusion burden in lung transplant recipients.

Methods: We conducted a retrospective cohort study of 952 adult lung transplant recipients. Anemia severity was defined by the lowest hemoglobin within 6 months before transplant and categorized as ≥ 10 g/dL, 8– < 10 g/dL, or < 8 g/dL. RBC burden was defined as the sum of preoperative and intraoperative transfusions, and high burden as ≥ 4 units. Multivariable linear and logistic regression models adjusted for age, sex, body mass index, donor age, and pre-transplant creatinine.

Results: In our study, hemoglobin level was < 10 g/dL in 120 patients (12.6%), including 42 (4.4%) with Hb < 8 g/dL. Mean RBC transfusion was 0.04 ± 0.35 units preoperatively, 0.75 ± 1.81 units intraoperatively, and 2.22 ± 5.77 units postoperatively. Transfusion burden increased progressively with worsening anemia in unadjusted analyses. Iron therapy was used in 27 (2.8%) patients and erythropoiesis-stimulating agents in 20 (2.1%; 5 epoetin, 15 darbepoetin) with higher use among patients with severe anemia. Among patients with hemoglobin < 10 g/dL and < 8 g/dL, IV iron was associated with higher unadjusted transfusion, while ESA showed no association with PRBC use. In adjusted models, neither anemia severity nor anemia-directed therapy independently predicted transfusion burden. Pre-transplant creatinine was the only independent predictor (OR 2.00, 95% CI 1.27–3.07; p = 0.002) (Figure).

Conclusions: In our cohort, RBC transfusion occurred mainly intraoperatively and postoperatively. Anemia-directed therapy was infrequently used and did not independently reduce transfusion, even in patients with hemoglobin < 10 g/dL or < 8 g/dL.

Figure (abstract P144) Independent predictors of RBC transfusion burden

P146 Observational real-life study of the use of octaplasLG® in France

Y Benhamou 1 , M Gareis 2 , P Poullin 3

1 Hôpital Charles-Nicolle, Rouen, France, 2 Octapharma Pharmazeutika Produktionsges.m.b.H, Vienna, Austria, 3 Aphérèse, APHM – Hôpital de la Conception, Marseille, France

Critical Care 2026, 30 (Suppl 1): P146

Introduction: This study aimed to describe the conditions of use of octaplasLG®, a pooled solvent/detergent-treated and filtered human plasma product. Although octaplasLG® is indicated for a variety of uses, real-world clinical data are limited.

Methods: This was a prospective, non-interventional, post-marketing study of patients receiving plasma infusions with octaplasLG® (Octapharma) at 14 hospitals/clinics in France. Primary endpoints were the indication for transfusion, degree of urgency, ordering department and infusion characteristics. Secondary endpoints were adverse reactions (AEs) and time to platelet count (PC) normalisation in patients with thrombotic thrombocytopenic purpura (TTP).

Results: In total, 243 patients received at least 1 infusion of octaplasLG®. Indications for use were therapeutic plasma exchange (TPE) procedures (56.8%), complex deficiency of coagulation factors (CFs; 40.7%) and substitution therapy in congenital CF deficiencies (2.5%). OctaplasLG® posology (mean ± SD) was 25.7 ± 21.9 mL/kg, and was higher for TPE procedures (39.0 ± 20.4 mL/kg) than for complex deficiency of CFs (7.7 ± 4.1 mL/kg) or substitution therapy in CF deficiencies (14.3 ± 5.8 mL/kg). The Figure shows usage by diagnosis and hospitalisation emergency level; overall, 54.7% of patients who received octaplasLG® were hospitalized in emergency. Overall, 27 patients (11.1%) had 70 AEs. AEs occurred within 24 h post-infusion in 3 patients (1.5%): 1 with coagulopathy due to complex deficiency of CFs experienced ischaemic stroke; 1 with thrombotic microangiopathy (TMA) experienced vomiting, paraesthesia and visual impairment; 1 with another diagnosis experienced erythema, hot flush and malaise. For 29 patients with TTP in whom treatment was deemed effective, the median time to PC normalisation was 5 days.

Conclusions: This study described real-life use of octaplasLG® and confirmed its safety and efficacy in the whole population across a range of diagnoses, including its use for TPE treatment in patients with TMA such as TTP.

Figure (abstract P146) Hospitalization emergency level according to main diagnostic

P148 Gelofusine administration in critically ill trauma patients is not associated with adverse renal or coagulation outcomes

J Boesch 1 , J Gebetsberger 1 , P Tscholl 2 , P Lichtenberger 1 , D Niederbrunner 1 , D Fries 1 , M Bachler 1

1 Medical University Innsbruck, Department of Anaesthesiology and Intensive Care Medicine, Innsbruck, Austria, 2 Data Lab Hell GmbH, Zirl, Austria

Critical Care 2026, 30 (Suppl 1): P148

Introduction: This study evaluated the safety of Gelofusine use in trauma patients admitted to the ICU, focusing on its potential association with acute kidney injury (AKI), coagulation impairment, and mortality. Gelatin-based volume therapy remains controversial, particularly regarding renal effects. The European trauma guideline advises restricted use of gelatin solutions: they should not be applied as standard-of-care therapy. Initial resuscitation should rely on crystalloids despite their negligible volume-expanding effect, while gelatin may be considered only in selected situations and with great caution [1].

Methods: We conducted a retrospective single-center cohort study of 220 adult trauma patients treated in the ICU at Innsbruck University Hospital. Data from the prehospital phase, emergency room, operating room, and ICU days 1–7 were analyzed. AKI was assessed using KDIGO and AKIN criteria; coagulation via FIBTEM; and outcomes included mortality, need for renal replacement therapy (RRT), fluid overload, and hemodynamic instability. Multivariable mixed-effects models controlled for relevant confounders.

Results: The overall in-house mortality was 16.4%, which was lower than predicted by national trauma registry data (Figure). Although higher Gelofusine doses were administered to sicker patients (e.g., those with higher lactate, shock, or AKI at admission), Gelofusine was not independently associated with worsening renal function, RRT, or coagulation impairment. Instead, renal outcomes were predominantly driven by early AKI, fluid overload, and baseline creatinine.

Conclusions: Gelofusine use was safe in this ICU trauma population and not linked to renal or coagulation-related harm. Its administration reflected illness severity rather than causing worse outcomes. Notably, despite relatively frequent Gelofusine use, overall morbidity and mortality remained below national and international benchmarks.

Reference Rossaint R et al. Crit Care 2023;27:80

Figure (abstract P148) In-house mortality by ISS of ICU patients at Innsbruck University Hospital compared to national DGU registry (red)

P150 Albumin structural and conformational conservation in Vialebex® compared with other available therapeutic albumin products: an in vitro study

Z Farhane, M Bilong, M Le Boedec, V Blanchard, A Besle, A Seifert

LFB Biotechnologies, Les Ulis, France

Critical Care 2026, 30 (Suppl 1): P150

Introduction: Human serum albumin (HSA) is an effective plasma expander and antioxidant used as infusion in intensive care unit for critical patients with severe burns or septic shock or hypoalbuminemia or decompensated cirrhosis. These emergencies are characterised by a reduction in total effective HSA concentration and a significant structural and functional alterations. It is important to conserve the structural integrity of albumin to maximise clinical effectiveness by minimising albumin oxidation and maintaining its interaction to neonatal Fc receptor (FcRn) to increase albumin recycling. We investigated potential structural differences among albumin products.

Methods: The study was performed on five albumin commercial products Albutein® 25%/Albunorm® 20%/Alburex® 20%/Flexbumin® 25% compared with Vialebex® 20%. Albumin’s isoforms distribution was determined by ion exchange chromatography and affinity to FcRn receptor was analysed by Surface Plasmon Resonance.

Results: Vialebex® batches contained on average a higher proportion of non-cysteinylated HSA (32.2 ± 1.2 vs range of other albumin products [15.8 ± 2.3;22.2 ± 13.3%]), a lower proportion of oxidised HSA compared with the other albumin products (15.5 ± 0.4 vs [27.4 ± 11.8;31.6 ± 15.7%]) and lower batch-to-batch variability. Vialebex® had a higher affinity for FcRn receptor driven by a faster association rate and a lower dissociation. Mean dissociation rate for Vialebex® was 3.85E-06 M, compared with the other albumins, which ranged from 4.73E-06M to 5.53E-06M (Table).

Conclusions: Vialebex® presented the highest level of non-cysteinylated isoform, the lowest oxidised one and the better affinity to FcRn receptor. The lower proportion of oxidised HSA in Vialebex® may explain its greater antioxidant potential, compared with other albumins. Preservation of structural and conformational integrity and superior antioxidant effect of Vialebex® could be advantageous in the management of critical patients.

Table (abstract P150) Relative quantification of albumin’s isoforms and dissociation rate of albumin towards FcRn receptor

P152 Optimal fluid resuscitation patterns in sepsis: a multi-center phenotype discovery and causal inference study

S Gao, B Zhang, Y Zhang, M Deng, X Zhang, L Tang, W Xu, M Luo, Y Tian, T He

Foshan Hospital of Traditional Chinese Medicine, ICU, Foshan, Guangdong Province, China

Critical Care 2026, 30 (Suppl 1): P152

Introduction: While the Surviving Sepsis Campaign recommends a fixed 30 mL/kg initial fluid volume [1], the "one-size-fits-all" approach remains debated. Moving beyond the binary "liberal vs. restrictive" paradigm, we hypothesized that unsupervised machine learning combined with causal inference could deconstruct clinical heterogeneity, identifying a precise therapeutic window associated with better outcomes than current standards.

Methods: We conducted a multi-center retrospective study (MIMIC-IV, n = 3,904; eICU-CRD, n = 6,266). Dynamic Time Warping clustered 48-h fluid patterns. IPTW mitigated confounding. Causal effects on mortality were estimated via subgroup analyses by baseline lactate (≤ 2 vs. > 2 mmol/L). Contour heatmaps visualized fluid-lactate-vasopressor interactions.

Results: DTW distinguished three clinical phenotypes: Restrictive, Moderate (25–40 mL/kg), and Liberal. In IPTW-adjusted analysis, the "Moderate" phenotype exhibited a robust survival advantage compared to the Restrictive baseline in both MIMIC-IV (HR 0.85, 95%CI 0.71–1.01) and eICU-CRD (HR 0.78, 95%CI 0.62–0.98). Subgroup analysis revealed this protective effect was most pronounced in patients with hyperlactatemia (lactate > 2 mmol/L), with odds ratios of 0.52 (95%CI 0.44–0.63, p < 0.001) in MIMIC-IV and 0.44 (95%CI 0.35–0.54, p < 0.001) in eICU-CRD. Contour heatmaps revealed that survival probability was highest in the 25–40 mL/kg range, particularly among patients requiring low-to-moderate vasopressor support, forming a U-shaped mortality curve with elevated risks at both extremes (Figure).

Conclusions: Using data-driven phenotyping, we identified a "Moderate" fluid strategy that is associated with lower mortality compared to restrictive or liberal extremes, particularly in hypoperfused patients. These findings support an optimal-window paradigm, suggesting that personalizing resuscitation within a 25–40 mL/kg window may offer superior outcomes over fixed targets.

Reference Evans L et al. Intensive Care Med 2021;47:1181–1247

Figure (abstract P152) Optimal survival is associated with a moderate fluid resuscitation strategy (25–40 mL/kg), distinct from restrictive or liberal approaches

P153 Validity of the initial distribution volume of glucose as a preload indicator under cardiac tamponade: an experimental study in pigs

K Noto, E Hashiba, S Uchida, A Ishii, J Saito

Hirosaki University Graduate School of Medicine, Department of Anesthesiology, Hirosaki, Japan

Critical Care 2026, 30 (Suppl 1): P153

Introduction: The initial distribution volume of glucose (IDVG) reflects the central extracellular fluid volume and is used as an indicator of cardiac preload [1]. Cardiac tamponade (CP) is a typical model of obstructive shock in which venous return is impaired. The study aimed to evaluate the validity of the IDVG as a preload indicator under CP in pigs.

Methods: After approval of the animal ethical committee of Hirosaki University, six anesthetized pigs were used. Cardiac output (CO), intrathoracic blood volume (ITBV), stroke volume variation (SVV), and CVP were measured using the PiCCO (Pulsion Medical Systems, Germany). The IDVG was calculated using a one-compartment model after intravenous injection of glucose (2 g), as previously reported [2]. In the CP protocol, an aortic occlusion balloon (Edwards Lifesciences, Japan) was inflated within the pericardial space to produce CP state which showed approximately a 1.5-fold CVP increase and 40% CO reduction. Measurements were obtained 5 min later. Fluid volume loading (10 mL/kg Hydroxyethyl starch) was performed with or without CP to assess volume responsiveness of hemodynamic indices and IDVG. Data were expressed as the mean ± SD/SEM, and the statistical analysis was performed with RM-ANOVA, followed by Dunnett’s test.

Results: CP significantly decreased CO and ITBV and increased SVV, whereas IDVG remained unchanged. IDVG significantly increased after fluid volume loading regardless of CP status, while CO increased only when fluid loading was performed without CP (Figure).

Conclusions: IDVG did not change in response to CP-induced obstructive shock and increased with fluid loading even under CP. These findings suggest that IDVG reflects central extracellular fluid volume and may serve as a preload indicator similar to stressed volume, which is related to venous return.

References Ishihara H et al. Intensive Care Med 2000;26:1441–8 Kasai T et al. J Anesth 2017;31:95–102

Figure (abstract P153) Hemodynamic changes during the cardiac tamponade protocol with volume loading. Systolic blood pressure (upper left), cardiac output (upper right), initial distribution volume of glucose (IDVG, lower left), and intrathoracic blood volume (ITBV, lower right) in six anesthetized pigs at baseline (Control), during cardiac tamponade (Tamp), after balloon deflation (PostTamp), during cardiac tamponade with volume loading (Tamp + Vol), and after tamponade release following volume loading (PostTamp). Values are expressed as mean ± SD. * p < 0.05, ** p < 0.01 vs Control

P154 Fluid responsiveness and changes in venous congestion and lung water during volume expansion in critically ill patients: a multicentre observational study

X Si

The First Affiliated Hospital, Sun Yatsen University, Critical Care Medicine, Guangzhou, China

Critical Care 2026, 30 (Suppl 1): P154

Introduction: The relationship between fluid responsiveness and right-and left-sided congestion remains underexplored. This study aimed to delineate the dynamic behaviour of venous congestion and extravascular lung water index (EVLWI) during a fluid challenge depending on the concomitant changes in cardiac index (CI).

Methods: In patients from three intensive care units, for whom a 500-mL fluid challenge was administered, we retrospectively analysed CI, CVP, venous excess ultrasound (VExUS), and EVLWI, which had been prospectively recorded. A VExUS congestion point was calculated from 0 to 7 by assigning 1 point to each degree of abnormality for the 4 investigated veins. A subgroup analysis was planned in patients with ARDS.

Results: We analysed 64 patients, of whom 42 (66%) were fluid responders (FR +) defined by a CI increase ≥ 15% with fluid infusion. Before the fluid challenge, CVP was lower in FR + than in fluid non-responders (FR-) (7.3 [2.9–10.3] vs. 10.6 [8.2–13.0] mmHg, respectively, p = 0.002). VExUS grades and congestion points were not different between FR + and FR- (Grade 0: 62% vs. 55%, respectively, p = 0.601; congestion points: 1.0 [0.0–2.3] vs. 2.0 [1.0–3.0], respectively, p = 0.053). EVLWI was also similar between groups. Following fluid administration, VExUS grade deterioration occurred in 5% of FR + versus 73% of FR − ( p < 0.001) (Figure). After the fluid challenge, abnormal VExUS grades were more prevalent in FR − than in FR + (91% vs. 43%, respectively, p < 0.001), and congestion points were higher (4.0 [3.0–5.0] vs. 1.5 [1.0–3.0], respectively, p < 0.001). CVP increased by 1.4 [0.4–2.4] mmHg in FR + and 2.0 [1.1–3.5] mmHg in FR- ( p = 0.064). Among 25 patients with ARDS, EVLWI increased more than in patients without ARDS, in both FR- (by 1.7 [0.9–3.3] vs. 0.7 [0–1.4] mL/kg, respectively, p = 0.046) and FR + (by 1.0 [-0.6–2.5] vs. 0 [-0.7–0.4] mL/kg, respectively, p = 0.009).

Conclusions: A fluid challenge worsened venous congestion, assessed by VExUS as well as CVP, in fluid non-responders, while it was not in fluid responders.

Figure (abstract P154) Comparison of VExUS grading and its dynamic changes following a fluid challenge in FR + (a) and FR- (b) patients

P155 Can ultrasound-derived jugular venous Doppler waveform reflect fluid intolerance in acute circulatory failure? A prospective, dual-center observational study

WN Zhu 1 , WL Song 1 , CW You 1 , RL Chen 2 , YL Lu 2 , JF Wu 1 , XD Guan 1 , X Si 1 , R Shi 1

1 The First Affiliated Hospital of Sun YatSen University, Department of Critical Care Medicine, Guangzhou, China, 2 Longgang Central Hospital, Department of Critical Care Medicine, Shenzhen, China

Critical Care 2026, 30 (Suppl 1): P155

Introduction: Fluid resuscitation is a cornerstone of management in acute circulatory failure, yet fluid overload carries significant risks. Accurate assessment of systemic venous congestion is therefore crucial. Venous excess ultrasound (VExUS) has known limitations [1]. Thus this study aimed to evaluate the potential ability of a hands-free, non-invasive jugular Doppler device (CVD) for estimating VExUS.

Methods: This prospective, dual-center observational study enrolled patients with circulatory failure (mean arterial pressure < 65 mmHg or receiving vasopressors) who were scheduled for a fluid challenge (FC) (500 mL Ringer’s lactate in 10–15 min) and monitored with PiCCO. Venous congestion grading by CVD and VExUS was performed before and after FC by two experienced blinded operators. Spearman correlation was used to assess overall agreement. The Wilcoxon test compared fluid responder (FR +) and non-responder (FR -) subgroups, and repeated measures correlation (rrm) evaluated trending ability.

Results: From July 2024 to August 2025, a total of 41 patients (mean age 61 ± 17 y) with 29 males (71%) were included. Among them, 88% were on norepinephrine (0.51 ± 0.59 μg/kg/min), and 85% on mechanical ventilation. The mean SOFA score was 9 ± 4. There was no diffrence regarding fluid balance between two groups ( p = 0.85). In FR - patients, VExUS grades increased after fluid challenge, with 54.6% progressing to Grade 2, whereas FR + patients exhibited stable grades. CVD showed consistent trends with VExUS in both groups. Repeated measures correlation between CVD and VExUS was rrm(32) = 0.55, 95%CI [0.265–0.751], p < 0.001; CVD vs. CVP rrm(32) = 0.51 95%CI [0.211–0.725], p = 0.002; CVP vs. VExUS rrm(32) = 0.43, 95%CI [0.141–0.647] p = 0.005 (see Figure).

Conclusions: CVD shows promising concordance with VExUS and may better reflect systemic venous congestion. Though not a full replacement, CVD offers valuable, continuous insight into fluid intolerance in critically ill patients.

Reference Longino A et al. Crit Care 2023;27:205

Figure (abstract P155) Correlation analysis of CVD, VExUS and CVP

P156 Venous excess ultrasound score is a marker of mean circulatory filling pressure in a porcine model of systemic inflammation

BK Lakatos 1 , BA Barta 1 , B Lonkai 2 , K Marosi 1 , S Spiesshofer 1 , A Kovacs 3 , E Németh 1 , B Merkely 1 , T Radovits 3 , Z Túróczi 1

1 Semmelweis University, Heart and Vascular Center, Budapest, Hungary, 2 Semmelweis University, Department of Intensive Therapy, Budapest, Hungary, 3 Semmelweis University, Department of Experimental Cardiology and Surgical Techniques, Budapest, Hungary

Critical Care 2026, 30 (Suppl 1): P156

Introduction: Hypervolemia resulting in venous congestion is detrimental to patients in the intensive care unit, however, accurately assessing or even predicting it with routinely accessible techniques remains a challenge. Venous excess ultrasound (VEXUS) score is a noninvasive method, which aims to achieve this by integrating results from visceral venous flow curves. There have been several studies confirming that higher VEXUS scores are associated with increased morbidity attributed to hypervolemia, but this relationship has never been confirmed. Our aim was to examine the relationship of VEXUS to venous congestion in a porcine model of systemic inflammation and its control group.

Methods: We examined 9 pigs (Zymosan-induced systemic inflammation n = 6, sham controls n = 3, weighing 20–30 kgs). After general anaesthesia, we performed baseline ultrasound measurements for VEXUS scoring, measured cardiac output with transpulmonary thermodilution and determined mean circulatory filling pressures (MCFP) using a validated method based on Guyton’s principle. Later we induced hypervolemia in two stages (giving 60 mL/kg crystalloid/stage) with the reassessment of every parameter.

Results: Baseline MCFP was 14.3 ± 1.1, which increased to 16.5 ± 1.7 and 18.4 ± 1.9 mmHg with each volume load respectively. Vexus score showed similar increase from baseline grade 1.1 ± 0.4 to 1.9 ± 0.8 and 2.4 ± 0.7. Using repeated measure statistics, both parameters displayed a significant increase with loading state (MCFP: p < 0.001, VEXUS: p = 0.002). In case of MCFP, the increments significantly differed from each other ( p < 0.001 for every pairwise comparison). MCFP correlated significantly with the VEXUS score (r = 0.88, r 2 = 0.78, p < 0.001) (Figure), and regression analysis suggests that for each VEXUS score increment MCFP increases by 2.9 ± 0.4 mm Hg.

Conclusions: In this animal model of systemic inflammation and its sham control, VEXUS score was strongly associated with MCFP, potentially confirming the previous clinical assumption about the method.

Figure (abstract P156) Correlation between mean circulatory filling pressure (MCFP) and VEXUS score

P157 Velocity-time integral and stroke volume measured in the ascending aorta for prediction of volume responsiveness in mechanically ventilated adults with septic shock

S Bhattacharjee 1 , B Kayarat 2 , AA Kundar 2 , BR Ray 2 , S Maitra 2

1 All India Institute of Medical Sciences, Anaesthesiology, Pain Medicine Critical Care, New Delhi, India, 2 All India Institute of Medical Sciences, New Delhi, India

Critical Care 2026, 30 (Suppl 1): P157

Introduction: Velocity time integral (Ao-VTI) and stroke volume (Ao-SV) can be estimated from spectral Doppler analysis of ascending aortic blood flow measured at the suprasternal notch [1]. We hypothesized that change Ao-VTI and Ao-SV will be able to identify volume responsiveness in mechanically ventilated critically ill adults with septic shock and also will be an acceptable alternative of left ventricle- VTI (LV-VTI) and left ventricle SV (LV-SV) measured by transthoracic echocardiography.

Methods: Adult patients with a diagnosis of septic shock were recruited. LVOT-VTI, LVOT- SV, Ao-VTI and Ao-SV were measured before and after a passive leg raising (PLR) maneuver. An increase in LVOT-VTI (ΔLVOT-VTI) > 12% after PLR was considered as volume responsiveness. Predictive ability of change in Ao-VTI (ΔAo-VTI) after PLR was evaluated by area under the receiver operator characteristics curve (AUROC). Agreement between LV-VTI and Ao-VTI was evaluated by mixed- effect Bland- Altman analysis.

Results: ΔAo-VTI was a decent predictor of volume responsiveness [AUROC (95% CI) 0.82 (0.68- 0.95), p < 0.001] when compared against the ΔLVOT-VTI as gold standard. The best cut-off was 8.5% with a sensitivity of 79.2%, specificity of 86.2% and accuracy of 83% to predict fluid responsiveness. There was statistically significant linear correlation between ΔLVOT-VTI and ΔAo-VTI [rho = 0.49, p < 0.0001]. The mixed effect Bland- Altman agreement analysis reported bias of –1.8 with limit of agreement of (-0.31, -3.3) between LVOT-VTI and Ao-VTI (Figure).

Conclusions: The ΔAo-VTI with PLR maneuver had moderate predictive ability for volume responsiveness. It has a decent sensitivity and high specificity and can be used in for assessment of volume responsiveness, particularly when it is difficult to obtain topical four chamber view. The limits of agreement between LVOT-VTI and Ao-VTI needs further evaluation as a large number of data points were outside the limit of agreement.

Reference Sanfilippo F et al. J Ultrasound. 2025;28:931–941

Figure (abstract P157) Bland- Altman plot showing agreement between LVOT-VTI and Ao-VTI

P159 Optimization of postoperative fluid therapy using biomarkers and bioelectrical impedance analysis integrated in artificial intelligence model

VA Crisan 1 , CC Cobilinschi 1 , A Dumitriu 1 , A Andrei 1 , L Mirea 1 , I Darie 1 , A Wong 2

1 Emergency Clinical Hospital of Bucharest, Intensive Care Unit, Bucharest, Romania, 2 Kings College Hospital, Intensive Care Unit, London, UK

Critical Care 2026, 30 (Suppl 1): P159

Introduction: Optimizing postoperative fluid therapy is essential for reducing complications and supporting recovery, yet conventional static parameters may miss early or subclinical imbalance [1,2]. This study evaluates the combined use of the Capillary Leakage Index (CLI), the Vascular Leakage Index (VLI), and bioelectrical impedance analysis (BIA) for individualized postoperative fluid assessment [3].

Methods: Adults (> 18 years) admitted to the ICU after abdominal surgery or multiple trauma were included; pregnancy, severe cardiovascular disease, chronic dialysis, and major limb amputations were exclusion criteria. At ICU admission, CRP, albumin, hematocrit and BIA-derived TBW, ECW and ICW were measured to calculate CLI and VLI, with repeat assessment on day 4. A planned sample of 84 patients allows correlational analysis using Pearson-Spearman methods.

Results: Preliminary data from 21 patients showed four significant correlations. VLI at 72 h demonstrated a strong inverse association with lactate on admission. CLI remained stable over time, correlating between admission and day 4, and also showing a moderate correlation with lactate on day 4 (Figure). ECW correlated strongly with TBW. No significant associations were identified between BIA parameters and CLI or VLI, indicating that capillary and vascular leakage may evolve independently from whole-body fluid distribution after surgery.

Conclusions: These findings suggest that CLI and VLI capture meaningful postoperative fluid shifts, and further enrollment will clarify their clinical value for individualized postoperative fluid management.

References Ostermann M et al. Br J Anaesth 2024;133:1263–1275 Makaryus R et al. Br J Anaesth 2018;120:376–383 Gonzalez-Fajardo J et al. Eur J Vasc Endovasc Surg 2009;37:538–43

Figure (abstract P159) Scatter plot of the strongest statistical correlations

P160 Personalized fluid resuscitation reduces mortality in septic shock as compared with fixed-volume approach – a systematic review and meta-analysis of randomized controlled trials

G Nagy 1 , J Hollosi 2 , C Turan 2 , D Laczko 2 , Z Sipos 2 , L Zubek 2 , Z Molnar 2

1 Semmelweis University, Department of Emergency Medicine, Budapest, Hungary, 2 Semmelweis University, Budapest, Hungary

Critical Care 2026, 30 (Suppl 1): P160

Introduction: Immediate fluid resuscitation plays a pivotal role in sepsis management. It remains unclear whether a fixed-volume or personalized strategy is more beneficial. Our aim was to compare effectiveness and safety of personalized vs. fixed-volume resuscitation in septic patients in a systematic review and meta-analysis.

Methods: We conducted a systematic literature search on PubMed, EMBASE and CENTRAL on October 30, 2024. The pre-study protocol was registered with PROSPERO (ID: CRD42024601970). Randomized controlled trials investigated septic patients who received fluid therapy in a personalized way during their initial resuscitation and reported the outcomes of our interest. The meta-analysis was performed using META packages in R with a random-effects model. Risk of bias was assessed using RoB2.

Results: The selection yielded 10 eligible randomized controlled trials (RCTs) with 1,011 patients. Data from 9 RCTs (n = 901) revealed significantly reduced odds of 30-day mortality, (odds ratio: 0.62; 95% confidence interval: 0.42–0.93) (Figure); however, there was no significant difference in the requirement for renal replacement therapy (odds ratio: 0.77; 95% confidence interval: 0.23–2.55), duration of mechanical ventilation (mean difference: 0.27; 95% confidence interval: -3.09–3.63), vasopressor therapy (mean difference: -3.70; 95% confidence interval: -32.88–25.48) and length of hospital (mean difference: -0.87; 95% confidence interval: -4.97–3.25) or intensive care unit stay (mean difference: 0.44; 95% confidence interval: -1.90–2.77).

Conclusions: Personalized fluid resuscitation, compared with fixed-volume resuscitation, significantly reduced 30-day mortality in septic patients.

Figure (abstract P160) Forest plot Illustrating the odds of 30-day mortality

P161 Trendelenburg maneuver to predict fluid responsiveness in patients under mechanical ventilation with spontaneous breathing: a prospective study

N Hemtanon 1 , N Raykateeraroj 1 , S Kongsayreepong 1 , T Yuyen 1 , P Boorapapon 1 , Y Hikasa 2 , S Laoamornphunkul 1 , N Kitisin 1

1 Mahidol University, Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand, 2 Austin Hospital, Department of Intensive Care, Victoria, Australia

Critical Care 2026, 30 (Suppl 1): P161

Introduction: Inappropriate fluid management is associated with adverse outcomes in critically ill patients. The Trendelenburg maneuver (TM), which transiently increases cardiac preload through a head-down tilt and operates on the same principle as passive leg raising for fluid responsiveness assessment [1], may offer a practical adjunct in light-sedated patients under mechanical ventilation (MV) with spontaneous breathing activity (SBA).

Methods: In this single-center, prospective study, the patients with signs of tissue hypoperfusion under MV with SBA in a surgical ICU underwent the TM which consisted of a sequential assessment of hemodynamic parameters at baseline supine position (T0), reverse Trendelenburg + 10° (T1), Trendelenburg − 13° (T2), return to supine before fluid loading (F0), and reassessment after a 4 mL/kg infusion of 5% albumin over 15 min (FL) as illustrated in the Figure. Cardiac index (CI) and its surrogates were measured at each step with FloTrac™/HemoSphere™. Fluid responder (FR) was defined as a ≥ 10% increase in CI from F0 to FL. The diagnostic performance of the TM was evaluated using the area under the receiver operating characteristic curve (AUROC).

Results: Among 38 patients, 21 were classified as FR. A TM-induced ΔCI > 0.15 L/min/m 2 yielded an AUROC of 0.78 (95% confidence interval 0.64–0.93), with 52.4% sensitivity and 82.4% specificity; however, more than 80% of patients lay within indeterminate gray zones. A TM-induced Δ%CI > 6% showed similar performance, while ΔSVV and ΔPPV demonstrated lower but moderate accuracy. In sensitivity analyses, its performance was slightly lower among patients with norepinephrine < 0.1 µg/kg/min.

Conclusions: The TM was feasible and safe but showed limited and inconsistent diagnostic performance, with wide gray zones encompassing most patients. These findings render the test inconclusive for bedside decision-making; at most, it may serve as a supplementary assessment when passive leg raising is not feasible.

Reference Wang Z et al. Crit Care 2025;29:60

Figure (abstract P161) The protocol for the TM (Trendelenburg maneuver). T0 = supine position, T1 = reverse Trendelenburg, T2 = Trendelenburg, F0 = before fluid loading, FL = after fluid loading

P162 Perioperative myocardial injury phenotypes in cardiac surgery: cardiovascular biomarkers as prognostic indicators of death and new disability

MSY Thio 1 , TCD Rettig 1 , HJT Ruven 2 , MLP Langelaan 3 , MC Post 4 , PG Noordzij 5

1 Amphia Hospital, Anaesthesiology and Intensive Care, Breda, Netherlands, 2 St. Antonius Hospital, Clinical Chemistry, Nieuwegein, Netherlands, 3 Amphia Hospital, Result Laboratorium, Breda, Netherlands, 4 St. Antonius Hospital, Cardiology, Nieuwegein, Netherlands, 5 St. Antonius Hospital, Anaesthesiology, Intensive Care, and Pain Medicine, Nieuwegein, Netherlands

Critical Care 2026, 30 (Suppl 1): P162

Introduction: This study aimed to identify prognostic perioperative phenotypes of myocardial injury, in patients undergoing cardiac surgery using biomarkers for myocardial injury, cardiac dysfunction and inflammation.

Methods: Patients undergoing coronary artery bypass grafting, valve surgery or Bentall procedures were included. NT-proBNP (pg/mL), cTnT and GDF-15 were measured preoperatively, postoperatively and on postoperative day 1–3. Longitudinal latent class mixed effects models were used to identify phenotypes. Relative risk ratios adjusted for EuroSCORE II (RR (95% CI)) were calculated for new-disability and one-year mortality.

Results: In 1,154 patients, four perioperative phenotypes were identified. Phenotype 1 (n = 927) had normal pre-operative biomarker values and minimal postoperative myocardial injury, cardiac dysfunction or inflammation. This group had the lowest risk of new disability (26.1%) and one-year mortality (0.7%). Phenotype 2 (n = 45) had similar baseline biomarker levels, but more comorbidities and pronounced postoperative cardiac dysfunction (peak NT-proBNP 7,704 [6,168–9,418]), with RRs for new-disability of 1.7 (1.2–2.3) and one-year mortality of 7.7 (2.1–22.9). Phenotype 3 (n = 164) presented with elevated pre-operative NT-proBNP (2,032 [1,566–2,973]) and high prevalence of chronic heart failure (30%) and atrial fibrillation (38%). Despite limited additional perioperative deterioration, one-year mortality was higher (RR 4.3 (1.5–11.6)). Phenotype 4 (n = 18) was characterized by elevated preoperative NT-proBNP (4,948 [3,146–7,738]) and severe perioperative myocardial injury, inflammation and cardiac dysfunction. Outcomes were poor, with RRs for new-disability of 1.8 (1.0–2.7) and one-year mortality of 25.1 (9.2–46.4).

Conclusions: A perioperative cardiovascular biomarker panel identified one low-risk and three high-risk phenotypes of myocardial injury, with distinct patterns of cardiac dysfunction and inflammation, prognostic for new-disability and one-year mortality after cardiac surgery.

P163 Randomized comparison of intensive blood pressure control in patients with acute type B aortic dissection (RAID)

P Yu 1 , P Lan 1 , C Wu 2 , H Kang 3 , Z Liu 4 , S Hu 5 , M Yan 6 , J Sun 7 , J Zhou 8

1 Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Zhejiang, China, 2 Ganzhou People´s Hospital, Jiangxi, China, 3 West China Hospital, Sichuan, China, 4 Second Affiliated Hospital of Zhejiang University School of Medicine, Department of Vascular Surgery, Zhejiang, China, 5 Wuxi People´s Hospital, Department of Vascular Surgery, Jiangsu, China, 6 Chongqing Daping Hospital, Department of Cardiovascular and Vascular Surgery, Chongqing, China, 7 Lishui Central Hospital, Department of Vascular Surgery, Zhejiang, China, 8 Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Department of Critical Care Medicine, Zhejiang, China

Critical Care 2026, 30 (Suppl 1): P163

Introduction: The optimal perioperative systolic blood pressure (BP) for patients with acute type Stanford B aortic dissection (ABAD) was currently uncertain. Objective was to clarify whether early intensive BP lowering provides better clinical prognosis for patients with ABAD compared with conventional BP management.

Methods: A multicenter, prospective, randomized trial was conducted from January 2018 to March 2022 at seven hospitals in China. The trial was registered in the website of ClinicalTrial.gov ( NCT03001739 ). Participants were randomly assigned to receive intensive BP management (systolic BP target < 120 mm Hg, n = 163) or conventional BP management (systolic BP target 120–140 mm Hg, n = 169) after enrollment. The primary outcome is a composite in-hospital adverse outcome, including perioperative death, stroke, permanent paraplegia or hemiparesis, and renal failure requiring hemodialysis at hospital discharge.

Results: Among 332 patients randomized, mean age was 55 years and 280 (84.3%) patients were male. Among patients who received intensive BP management, 6.7% had a composite in-hospital adverse outcome, compared with 5.9% of patients who received conventional BP management, a non-significant difference (OR 1.15 [95% CI, 0.48-2.79], p = 0.93). The median hospital length of stay in the intensive BP management group was 16 days (IQR, 10–23 days), and the median hospital length of stay in the conventional group was 16 days (IQR, 10–21 days). The median perioperative maximal creatinine level during hospitalization in the intensive BP management group was 88.0 mmol/L (IQR, 71.4-121.5 mmol/L), and the median perioperative maximal creatinine level in the conventional group was 97.3 mmol/L (IQR, 80.0-128.0). 266 (80.1%) of 332 patients had received thoracic endovascular aortic repair.

Conclusions: In patients with ABAD, intensive BP lowering to within 120 mm Hg did not confer additional reductions in composite in-hospital adverse outcome over conventional BP of lowering of 120-140 mmHg.

P164 Hypotension endotypes during airway-management in critically ill patients: a hybrid deep-learning analysis

VC Kurucz 1 , CA Den Otter 1 , J Schuurmans 2 , JTM Tol 1 , SR Rellum 2 , BJP Van der Ster 2 , APJ Vlaar 3 , E Kho 2 , J Schenk 4 , DP Veelo 2

1 Amsterdam UMC, Anesthesiology and Intensive Care Medicine, Amsterdam, Netherlands, 2 Amsterdam UMC, Anesthesiology, Amsterdam, Netherlands, 3 Amsterdam UMC, Intensive Care, Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam, Netherlands, 4 Amsterdam UMC, Department of Anesthesiology, Department of Intensive Care and Department of Epidemiology and Data Science, Amsterdam, Netherlands

Critical Care 2026, 30 (Suppl 1): P164

Introduction: Hypotension during airway management (e.g. intubation or tracheostomy) in critically ill patients is common. While monitoring detects hypotension, the cause often remains unclear, leaving treatment reliant on clinicians’ judgment. We aimed to identify hypotension endotypes using a hybrid deep-learning approach applied to high-resolution intensive care unit (ICU) hemodynamic data.

Methods: We analyzed 113 ICU patients with hypotension (MAP < 65 mmHg for ≥ 1 min) during airway management. Dimensionality reduction using a long short-term memory autoencoder was followed by Gaussian mixture modeling to identify clusters based on the following hemodynamic variables: stroke volume variation (SVV); stroke volume index (SVI); pulse rate (PR); systemic vascular resistance index (SVRI); and rolling standard deviation features. Endotypes were identified through unsupervised clustering and labeled by a clinical panel based on hemodynamic profiles. Internal validation used a 20% holdout dataset.

Results: From 265 hypotensive episodes, four endotypes were identified (Figure). The most common (69%) was labeled as “hypovolemia due to vasodilation”, with normal-to-high SVV, low SVI, and low-to-normal SVRI. The “hypovolemic” endotype (13%) showed high SVV, reduced SVI and SVRI, and tachycardia. “Vasodilation” (10%) was marked by low SVRI, high SVI, and low SVV. “Myocardial depression” (8%) involved low cardiac index driven by reduced SVI and a relative drop in PR, alongside elevated SVV, and increased SVRI. Internal validation confirmed accurate data representation and consistent clustering across training and holdout sets, with a median per-episode reconstruction error difference of 0.6 (95% CI: 0.3–1).

Conclusions: Unsupervised deep learning identified four distinct hypotension endotypes during airway management, which may inform mechanism-specific interventions and contribute to improved clinical decision-making.

Figure (abstract P164) Hemodynamic fingerprints of the four hypotension endotypes illustrated with density radar plots

P165 Tissue perfusion pressure, not mean arterial pressure, associated with 28-day mortality in septic shock: a cohort study using high-resolution waveform data

K Jin, H Chen, Y Yang

Southeast University, Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Nanjing, China

Critical Care 2026, 30 (Suppl 1): P165

Introduction: Despite achieving MAP targets (≥ 65 mmHg), tissue hypoperfusion often persists in septic shock. Flow is physiologically limited by critical closing pressure (Pcc); thus, the effective driver is tissue perfusion pressure (TPP = MAP-Pcc). We hypothesized that TPP predicts mortality better than MAP and sought a clinical threshold.

Methods: This retrospective study analyzed high-resolution (125 Hz) arterial waveforms from adults admitted to the ICU of a large tertiary academic medical center. Patients with sepsis requiring vasopressors within 24h were included. Pcc was estimated minute-by-minute using a validated physiological algorithm derived from beat-to-beat data [1]. The exposure was the 24h time-weighted average TPP. Primary outcome was 28-day mortality. Multivariable logistic/Cox regression and restricted cubic splines (RCS) were used, adjusting for confounders including SOFA, Vasoactive-Inotropic Score.

Results: Among 590 patients, 28-day mortality was 28.3%. Non-survivors had significantly lower TPP (median 32.1 vs. 38.1 mmHg, p < 0.001). In continuous multivariable models, higher TPP independently reduced mortality risk ( p < 0.001), whereas MAP showed no independent association ( p > 0.05). RCS revealed a non-linear L-shaped relationship ( p nonlinear < 0.001) with a sharp risk increase below approximately 39 mmHg (Figure). Patients with TPP < 39 mmHg had higher mortality vs. TPP ≥ 39 mmHg (35.2% vs. 17.5%; adjusted OR 0.45, 95% CI 0.28–0.74; p = 0.002). Higher TPP also correlated with more vasopressor-free and organ-failure-free days ( p < 0.001). Interaction analysis suggested stronger protective effects of TPP in patients with higher SOFA scores.

Conclusions: In septic patients requiring vasopressors, TPP, but not MAP, is independently associated with 28-day mortality. A TPP of approximately 39 mmHg may serve as a critical lower limit for maintaining effective organ perfusion. TPP represents a promising physiological target for hemodynamic optimization.

Reference Chandrasekhar A et al. Nat Med 2023;29:1998–2006

Figure (abstract P165) Restricted cubic spline analysis of TPP and 28-day mortality. The solid blue line represents the adjusted hazard ratio (HR) relative to the nadir (red dotted line, TPP ≈ 48.3 mmHg); the shaded area indicates the 95% confidence interval. The curve demonstrates a significant non-linear relationship ( p < 0.001), with risk increasing sharply as TPP falls below approximately 39 mmHg

P166 A porcine model of septic shock with fluid accumulation and prolonged resuscitation

HS Ly 1 , A Hammed 1 , H Dumargne 2 , R Lac 1 , V Louzier 1 , A Dargent 3

1 VetAgro Sup, Marcy l´Etoile, France, 2 Hospices Civils de Lyon, Oullins, France, 3 Hospices Civils de Lyon, LyonSud Hospital Critical Care Department, Oullins, France

Critical Care 2026, 30 (Suppl 1): P166

Introduction: Fluid overload in sepsis, driven by capillary leakage, poses a major challenge in managing septic shock. Capillary leakage is a central mechanism, but experimental data to guide targeted therapeutic approaches remain limited. It is therefore essential to develop robust preclinical models in order to explore strategies aimed at limiting its deleterious effects. We therefore developed a translational porcine model of Pseudomonas aeruginosa -induced septic shock with fluid overload, resuscitated over 24 h.

Methods: Sixteen female pigs (55 kg) were divided into three groups. control (CT, n = 4, no bacteria), the two other groups received an IV infusion of Pseudomonas aeruginosa (5 × 10⁸ CFU/mL) at short dose (SD, n = 6, 0.3 mL/20 kg/min for 90 min), and continuous dose (CD, n = 6, 0.1 mL/kg/h with hourly doubling over 6 h). Upon hypotension (MAP < 65 mmHg), resuscitation followed a standardized protocol (fluids ± norepinephrine). Data were collected over 24 h from the start of bacterial infusion.

Results: No sepsis was observed in the CT group, while all pigs in the SD and CD groups met sepsis criteria based on the porcine-adapted five-domain SOFA score. Septic shock developed in 33.3% of SD and 100% of CD animals. Twenty-four-hour survival was 100% (CT), 83.3% (SD), and 66.7% (CD). Significant differences were observed in fluid balance (1230, 5650, 7808 mL; p < 0.001), lung wet/dry ratio (2.35, 6.57, 5.75; p = 0.0008), kidney wet/dry ratio (2.78, 5.78, 5.09; p = 0.02), and combined pleural/peritoneal fluid accumulation (11, 255, 974 mL; p = 0.003) (Figure).

Conclusions: Continuous P. aeruginosa infusion effectively induced septic shock with significant fluid overload, providing a robust porcine model of sepsis-induced capillary leakage. The resuscitation protocol was efficient and allowed to reproduce the course of fluid accumulation during early septic shock.

Figure (abstract P166) Summarized results in the 3 groups of animals: control (CT, n = 4, no bacteria), short dose (SD, Pseudomonas aeruginosa 5 × 10⁸ CFU/mL 0.3 mL/20 kg/min for 90 min, n = 6), and continuous dose (CD, n = 6, 0.1 mL/kg/h with hourly doubling over 6h)

P167 The role of ICU nurses in hypotension management: knowledge, practices, and the potential for a nurse-driven protocol

PP Oomes 1 , M Groot 1 , J Schuurmans 2 , S Rellum 2 , F Paulus 1 , AP Vlaar 1 , DP Veelo 2 , W Stilma 1 , J Schenk. 2

1 Amsterdam UMC, Intensive Care, Amsterdam, Netherlands, 2 Amsterdam UMC, Anesthesiology, Amsterdam, Netherlands

Critical Care 2026, 30 (Suppl 1): P167

Introduction: Hypotension is common in the ICU and is associated with increased morbidity and mortality. ICU nurses play a key role in its detection and initial management, but their autonomy may be limited. Insight into their knowledge and perspectives regarding nurse-driven hypotension treatment is currently lacking. The aim of this study is to asses ICU nurses’ theoretical and practical knowledge of hypotension management and to identify perceived barriers to implementing a nurse-driven treatment protocol.

Methods: A single-center, cross-sectional survey was conducted among ICU nurses at Amsterdam UMC. The questionnaire assessed knowledge, clinical practices and attitudes toward nurse-led hypotension management.

Results: The response rate was 99% (N = 142). Nurses encountered hypotension in 55.1% of shifts. Over 80% supported nurse-led interventions, and 68.6% reported independently initiating treatment in 70% of hypotensive events (Figure). Knowledge accuracy exceeded 80% for treatment-related items. However, scores for complex hemodynamic interpretation were lower (36.4–48.1%). The most frequently reported barrier to implementing a nurse-driven protocol was uncertainty regarding patient inclusion and exclusion criteria.

Conclusions: ICU nurses frequently manage hypotension and support nurse-driven protocols, but knowledge gaps in advanced hemodynamic reasoning remain. Clear physiological criteria, structured education and decision-support tools may help ensure safe and effective nurse-led hypotension management in high-acuity settings.

Figure (abstract P167) Reported frequency, beliefs, and practices regarding interventions for hypotension alarms, including treatment choices and independent initiation of care

P169 A machine-learning digital twin for predicting vasopressor need in sepsis patients

L Mellhammar 1 , AM Scott 2 , E Malmström 2 , AG Gustafsson 2 , A Bakochi 3 , T Mohanty 2 , L Thelaus 2 , F Kahn 2 , J Malmström 2 , A Linder 2

1 Faculty of Medicine, Lund University, Department of Clinical Sciences, Lund, Sweden, 2 Faculty of Medicine, Lund University, Lund, Sweden, 3 Swedish Infrastructure for Biological Mass Spectrometry, Swedish Infrastructure for Biological Mass Spectrometry, Lund, Sweden

Critical Care 2026, 30 (Suppl 1): P169

Introduction: We postulated that a machine-learning digital twin model that incorporates clinical data and plasma proteome may predict which patients, with suspected sepsis, will require vasopressor treatment, already on admission to the emergency department, and before fluid challenge.

Methods: We have constructed a digital twin model for organ dysfunction in patients with suspected sepsis (n = 1613) using organ dysfunction-informed supervised projections of the blood plasma proteome at hospital admission. The proteome was analyzed by liquid chromatography mass spectrometry and demonstrate distinct protein profiles indicative of specific organ dysfunction [1]. We tested the digital twin model’s ability to predict vasopressor treatment out of proteome and clinical data available at admission.

Results: We analyzed a validation cohort (n = 1046) of patients with suspected sepsis and an external cohort (n = 350) with mixed emergency department patients. The digital twin model was able to aggregate patients together who received vasopressor treatment (Figure). Patients with a vasopressor risk score of ≥ 0.4 according to the digital twin model are up to 10-times more likely to receive vasopressor treatment and it is a stronger predictor of future vasopressor treatment than systolic blood pressure, AUC for the digital twin model 0.76 and for systolic blood pressure 0.62.

Conclusions: These findings suggest that proteome and clinical data can be used to accurately identify patients in need of vasopressor treatment already at the time-of-admission to the emergency department which could reduce potentially harmful fluid therapy and select patients for sparse beds in intensive care. Further it uncovers other clinically and molecularly similar patients who may benefit from a similar therapy. This general approach could also be applied towards other treatment types, unlocking the potential for precision medicine in sepsis.

Reference Scott A et al. medRxiv 2024; 10.1101/2024.03.20.24304575

Figure (abstract P169) Results

P170 Methylene blue as secondary vasopressor in septic shock: a single-center randomized controlled trial

L Li, Y Li, Y Liao, Z Qian, L Zhang

Xiangya Hospital, Central South University, Department of Critical Care Medicine, Changsha City, China

Critical Care 2026, 30 (Suppl 1): P170

Introduction: While methylene blue (MB) as a second-line vasopressor effectively reduces vasopressor dosage and duration, its impact on changing organ failure scores in patients with septic shock remains unclear.

Methods: Between Feb. 17, 2023, and Feb. 14, 2025, adult patients with septic shock receiving norepinephrine (NE) ≥ 0.25 μg/kg/min for over 2 h were screened. Participants were randomized using computer-generated numbers. The intervention group received a single intravenous infusion of 2 mg/kg MB in 100 mL of 0.9% normal saline over 20 min upon meeting inclusion criteria, while the control group continued NE monotherapy. If NE requirements reached ≥ 0.5 μg/kg/min for over 2 h, the attending physician decided whether to initiate other vasopressors (excluding MB). The primary outcome was the change in SOFA (Sequential Organ Failure Assessment) score at 72 h after inclusion (ΔSOFA = SOFA score at 72 h—baseline SOFA score). Secondary outcomes included time to shock resolution, ICU mortality, and length of ICU stay.

Results: Of 120 enrolled patients, 119 were included in the final analysis (60 in the MB group, 59 controls). The ΔSOFA score showed tendency of greater reduction in the MB group (–3.5 ± 3.4 vs. –2.4 ± 3.0, p = 0.068). Although NE doses were similar at baseline (0.19 [0.15, 0.17] vs. 0.15 [0.15, 0.17] μg/kg/min, p = 0.345), the MB group had significantly lower NE requirements at 72 h (0.0 [0.0, 0.19] vs. 0.25 [0.0, 0.50] μg/kg/min, p = 0.003). The median time to shock resolution was numerically shorter in the MB group (36.5 [20, 72] hours) than in controls (72 [22, 72] hours), though without significance ( p = 0.114). No statistical differences were observed in ICU mortality (41.7% vs. 52.5%, p = 0.235) or ICU length of stay (7 [4, 15] vs. 9 [5, 16] days, p = 0.682).

Conclusions: As adjunctive, a single dose of MB demonstrated a trend toward improved SOFA scores and significantly reduced NE requirements at 72 h in septic shock patients.

P171 Our experience with angiotensin 2: a mixed ICU perspective

I Vuksan, B Barbalic, M Bobinac, K Juricic, A Protic

University Hospital Centre Rijeka, Department of Anesthesiology, Intensive Care and Pain Medicine, Rijeka, Croatia

Critical Care 2026, 30 (Suppl 1): P171

Introduction: Angiotensin II (AT-II) has been recently discussed as third line therapy for refractory vasodilatory shock in septic patients based on the ATHOS-3 trial. However, its effectiveness in non-septic shock remains unclear. The objective of our study was to investigate AT-II hemodynamic response in different subgroups patients treated in mixed intensive care unit (ICU) [1,2].

Methods: Retrospective analysis of 36 patients in shock, refractory to 2 vasoactive drugs, receiving AT-II (2019–2024). The cause of shock in 30 (30/36, 83.3%) patients was sepsis, while others were hemorrhagic shock patients(6/36, 16.7%). Primary observed outcomes were norepinephrine (NE) dose reduction at 4 and 24 h, mean arterial pressure (MAP), and 28-day mortality. Secondary outcome followed changes in SOFA score at 24 h.

Results: Septic shock patients showed significant NE dose reduction (0.48 ± 0.12 to 0.16 ± 0.08 mcg/kg/min; 67% reduction, p < 0.001) and MAP improvement (58 ± 8 to 76 ± 5 mmHg; + 31%, p < 0.001) while nonseptic shock patients showed minimal NE reduction (0.52 ± 0.14 to 0.48 ± 0.13 mcg/kg/min; 8%, p = 0.521) and insignificant MAP change (62 ± 9 to 65 ± 8 mmHg; + 5%, p = 0.412) (Table). At 24 h, survivors showed lower SOFA score and better lactate levels. Despite hemodynamic improvement, overall 28-day mortality stayed high, 80.6% (septic 76.7%, polytrauma 100%). No thrombogenic complications were observed.

Conclusions: In our experience, AT-II showed different efficacy based on shock aetiology. There was a vasopressor-sparing effect and MAP improvement in septic shock patients, while poor results in polytrauma suggest RAAS dysregulation and disease etiology could be critical treatment determinants [2].

References Petrun AM et al. J Cardiothor Vasc Anesth 2025;39:3359-3367 Xourgia E et al. Shock 2024;62:155-164

Table (abstract P171) Changes in observed parameters

P172 Early identification of responders to angiotensin II in distributive shock: a real-world hemodynamic and endocrine-based approach

IC Cappellini, EC Schirru, LC Campagnola, FL Lai, SM Magazzini, VP Pavoni

Azienda USL Toscana Centro, Emergency and Critical Care, Prato, Italy

Critical Care 2026, 30 (Suppl 1): P172

Introduction: The clinical response to angiotensin II (ATII) in vasoplegic shock remains heterogeneous [1]. Identifying early responders may optimize timing, reduce catecholamine exposure, and improve outcomes. We retrospectively analyzed hemodynamic, endocrine, and clinical data from patients treated with ATII as a third-line vasopressor in distributive shock, integrating renin levels and dynamic norepinephrine (NA) response.

Methods: Consecutive ICU patients receiving ATII after norepinephrine and vasopressin were included. Baseline renin, APACHE II, and SOFA scores were recorded. Hemodynamic parameters and NA dose were monitored at baseline, 3h, and 6h post-ATII initiation. Responders were defined by ≥ 50% NA reduction at 6h ("LCR model"). An AIMRITE-derived early response index [2] (estimated NA reduction at 1h) was modeled to simulate rapid responders. VLAD and Cox analyses were performed for survival adjustment.

Results: Among 18 evaluable patients, 72% were classified as responders. Median baseline renin was higher in responders (292 [111–818] vs 146 [61–777] pg/mL), with earlier NA reduction (median Δ% t0 → t6 = − 25%). Early estimated NA reduction at 1h correlated with 6h response ( p < 0.01). Responders showed a higher rate of vasoactive weaning at 6h (67% vs 28%) and lower mortality trend. AIMRITE-modeled early response was associated with improved survival in Cox analysis (HR 0.42, 95%CI 0.18–0.95, p = 0.04).

Conclusions: Early hemodynamic response to ATII (within 1–3h) can identify true responders, supporting the AIMRITE physiological model. Prompt initiation and dynamic reassessment may enhance clinical outcomes and cost-effectiveness in distributive shock management. A multicenter registry is warranted to validate these findings.

References Khanna A et al. N Engl J Med 2017;377:419–430 Leisman D et al. Ann Intensive Care 2025;15:1522

P173 Renin-guided initiation of angiotensin II in catecholamine-refractory septic shock: an open-label randomized controlled trial.

M Benlabed 1 , S Benlabed 2 , R Gaudy 3 , V Sobkova 4 , R Mehyaoui 5 , A Benhamed 6 , A Aberkane 7 , A Metali 5

1 Lille University, Anesthesiology and Intensive care, Lille, France, 2 Free University of Brussels, Brussels, Belgium, 3 Lille University, Lille, France, 4 University of Prague, Prague, Czech Republic, 5 Algiers University, Algiers, Algeria, 6 University of Oran, Anesthesiology, Oran, Algeria, 7 University of Constantine, Constantine, Algeria

Critical Care 2026, 30 (Suppl 1): P173

Introduction: Renin is a key biomarker of renin–angiotensin–aldosterone system failure in septic shock. Elevated renin levels (> 180 pg/mL, median value) have been associated with impaired vascular responsiveness and increased mortality. Elevated plasma renin identifies septic shock patients with impaired angiotensin I–to–II conversion. Retrospective data [1,2] suggest these patients may benefit from exogenous angiotensin II (AngII). We hypothesized that a renin-guided strategy improves hemodynamics and outcomes in patients with cathecolamines refractory septic shock.

Methods: In this multicenter, open-label, randomized trial, 212 adults with catecholamine-refractory septic shock (≥ 0.2 μg/kg/min norepinephrine) and plasma renin around the median(180 pg/mL) were randomized 1:1 to angiotensin II plus standard care [3] or standard care alone [3]. Primary endpoint: achievement of MAP ≥ 75 mmHg at 3 h without increased catecholamines. Secondary endpoints: renin reduction, SOFA score at 24 h, vasopressor-free days at day 7, 28-day mortality. Continuous variables were compared using the Mann–Whitney test, categorical variables with χ 2 tests, and mortality with Cox proportional hazards.

Results: •Primary endpoint: 71% in AngII vs 38% in control ( p < 0.001). •Renin reduction at 3 h: − 58% [IQR − 44 to − 71] vs − 12% [− 3 to − 21] ( p < 0.001). •SOFA at 24 h: − 2.8 ± 1.3 vs − 1.1 ± 1.2 ( p < 0.01). •Vasopressor-free days (day 7): 3.1 ± 2.4 vs 1.7 ± 2.2 ( p = 0.004). •28-day mortality: 38% vs 52% (HR 0.67; 95%CI 0.48–0.94; p = 0.02) (Figure).

Conclusions: Renin-guided Ang II initiation in catecholamine-refractory septic shock improved early hemodynamics, accelerated renin normalization, and reduced 28-day mortality. Plasma renin is a practical biomarker to select patients likely to benefit from Ang II therapy. These findings support the development of a renin-guided strategy as a personalized approach to the management of refractory septic shock.

References Bellomo R et al. Crit Care 2020;24:43 Bellomo R et al. Am J Respir Crit Care Med 2020;202:9 Khanna A et al. N Engl J Med 2017;377:5

Figure (abstract P173) 28-day mortality AngII vs control

P174 Time-weighted mean vasopressor dose and clinical outcomes in a cohort of patients with septic shock

F Quilty 1 , M Renshaw 2 , Z Ilesanmi 3 , M Smith 3 , J Bannard-Smith 3

1 Manchester University NHS Foundation Trust, Manchester Royal Infirmary, Manchester, UK, 2 University of Manchester, Manchester, UK, 3 Manchester University NHS Foundation Trust, Manchester, UK

Critical Care 2026, 30 (Suppl 1): P174.

Introduction: Mortality is the most utilised outcome measure in clinical trials testing interventions for septic shock. An internationally agreed core outcome set has yet to be established. Duration of shock may be an outcome of interest, but previous measures of vasopressor dependence are insensitive to other indications for organ support and confounded by mortality. Time-weighted mean dose has been considered as an alternative measure of vasopressor dependence. We conducted a study describing the distribution of these measures in an observational patient cohort.

Methods: We retrospectively analysed a cohort with septic shock (Sepsis-3 criteria) admitted to an ICU in England over a year. Noradrenaline infusion rate (mcg/kg/min) was calculated hourly. Metaraminol was given a nominal value of 0.1. Days on vasopressors (DOV), days alive and vasopressor-free (DAVF) up to 28 days and time-weighted mean vasopressor dose (TMVD) for the hours on vasopressors were calculated. Values were calculated in the same way for survivors and non-survivors. Descriptive statistics were produced for the cohort. ROC curves were produced to assess each measure’s ability to discriminate ICU mortality and survival.

Results: We extracted data for 197 patients. Mean age was 61 (SD 14), 110/197 (56%) were male, the ICU mortality rate was 81/197 (41%). ICU survivors had 5.5 (SD 5.3) DOV, 22.5 (SD 5.3) DAVF and had a TMVD of 0.117 (SD 0.073) mcg/kg/min. Non-survivors had 5.4 (SD 4.8) DOV, 1.8 (SD 4.0) DAVF and had a TMVD of 0.398 (SD 0.551) mcg/kg/min. In discriminating for mortality, AUROC was 0.521 (95% CI 0.442—0.604) for DOV, 0.991 (0.979—0.998) for DAVF and 0.723 (0.642—0.799) for TMVD (Figure).

Conclusions: Time-weighted mean vasopressor dose may be a suitable secondary outcome in septic shock trials, with a lower mean dose considered favourable. Further validation is needed in a prospective cohort.

Figure 1 (abstract P174) ROC curve for time-weighted mean vasopressor dose

P175 Safety-aware reinforcement learning for vasopressor weaning in septic ICU patients

L Lijovic 1 , G Kim 2 , P Hilders 3 , J Han 2 , PWG Elbers 3 , WY Kim 2

1 Clinical Hospital Centre Sestre Milosrdnice, Intensive Care, Zagreb, Croatia, 2 Chung-Ang University Hospital, Adult Intensive Care, Seoul, South Korea, 3 Amsterdam UMC, Adult Intensive Care, Amsterdam, Netherlands

Critical Care 2026, 30 (Suppl 1): P175

Introduction: Reinforcement learning (RL) can discover treatment policies that optimise long-term outcomes, but in critical care a purely efficacy-driven reward risks unsafe recommendations. We demonstrate on a task of reducing vasopressor support, that an RL agent learns a strategy to wean faster than a clinician, while incorporating safety considerations, such as maintaining stable hemodynamics.

Methods: Using MIMIC-IV, we identified septic ICU patients receiving norepinephrine (NE) and vasopressin (VP) concurrently and realigned each stay to the hour of peak combined NE-equivalent dose. Vitals, laboratory data, organ support and treatments were aggregated hourly for up to 168 h or until death or discharge. State space consisted of 78 features, and observed clinician NE/VP titrations in 5% steps defined a nine-dimensional action space. A tiered reward combined large penalties for death and relapse after liberation, bonuses for ≥ 24 h off both vasopressors and survival at 7 days, modest rewards for favourable trends in lactate, SOFA and costs for vasopressor use, organ support and mean arterial pressure (MAP) outside 65–85 mmHg. A conservative Q-learning (CQL) agent trained on an 80/20 stay-level split with inverse-frequency action weighting; performance was assessed with fitted Q-evaluation (FQE) and compared with a behaviour-cloned clinician policy.

Results: We analysed 110,639 hourly decisions from 1128 patients. CQL achieved FQE-estimated return − 93.9, outperforming the clinician policy (− 67.5; Δ≈26.4). The agent agreed with observed clinician actions in 68.2% of steps (Figure) and most frequently recommended small down-titrations or maintenance of current dose, rarely up-titrating both NE and VP. Case studies showed maintained MAP within the 65–85 mmHg safety band during earlier and more sustained weaning.

Conclusions: CQL agent learned a weaning-oriented vasopressor policy that achieved higher estimated return than a clinician policy while largely respecting predefined hemodynamic safety targets.

Figure 1 (abstract P175) (A) Action agreement between the conservative Q-learning (CQL) agent and clinicians. Each cell shows the number of hourly decisions for each joint norepinephrine (NE) / vasopressin (VP) action pair in the 9-action discrete space (↓/ ↔ /↑ NE × ↓/ ↔ /↑ VP). (B) A random case study illustrating a septic ICU stay, with top panel plotting MAP and vasopressor doses, and bottom panel compares hourly clinician and agent actions

P176 Vasopressor use does not worsen sublingual microcirculation in a porcine model of non-traumatic hemorrhagic shock

MW Kim 1 , M Magnin 2 , T Schuhler 3 , T Victoni 4 , B Allaouchiche 3 , G Hoareau 5 , C Pouzot Nevoret 6

1 Agro Sup, SIAMU, Marcy L'Etoile, France, 2 VetAgro Sup, Unité de Physiologie, Pharmacodynamie et Thérapeutique, Marcy L'Etoile, France, 3 Université de Lyon, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Réanimation Médicale, Lyon, France, 4 VetAgro Sup, Unité de Pharmacie et de Toxicologie, Marcy L'Etoile, France, 5 University of Utah, School of Medicine, Nora Eccles Harrison Cardiovascular Research & Training Institute, Salt Lake City, Utah, USA, 6 VetAgro Sup, SIAMU, Marcy L'Etoile, France

Critical Care 2026, 30 (Suppl 1): P176

Introduction: Vasopressors can reduce fluid requirements in hemorrhagic shock resuscitation but may cause ischemic organ injury. We measured the effect of standard resuscitation alone or with either noradrenaline or vasopressin on sublingual microcirculation in a porcine hemorrhagic shock model.

Methods: Ethics approval was obtained (no. 1819). 15 female pigs, 60 – 65 kg, were anesthetized, instrumented, then bled in 2 stages (20 mL/kg in 20 min followed by 15 mL/kg in 15 min) to induce hemorrhagic shock. After a 90 min observation period, pigs were resuscitated with lactated Ringer’s and autologous whole blood (group C, n = 6), plus noradrenaline (0.2 µg/kg/min, group N, n = 5), or plus vasopressin (0.6 mU/kg/min, group V, n = 5), targeting MAP = 65 mmHg. Sublingual microcirculation was recorded at baseline, during the observation period then every hour for 6 h during the resuscitation period using sidestream darkfield microscopy (SDF; Microscan, The Netherlands) by 2 trained operators and analysed using proprietary software following published consensus guidelines [1]. SDF variables were analysed using linear mixed-effects models with time and group as fixed effects.

Results: 1 pig in group C died before resuscitation. The percentage of perfused vessels and small vessels decreased significantly during the 90 min observation period post-blood withdrawal (Figure). The heterogeneity index increased significantly for groups C and V over this observation period. For all pigs, there were almost no between-group differences in SDF variables over the resuscitation period aside from isolated periods for the De Backer score and heterogeneity index.

Conclusions: Vasopressor use did not significantly affect sublingual microcirculation compared to standard resuscitation. Investigation of vasopressor impact on vital organs in hemorrhagic shock should be continued.

Reference Ince C et al. Intensive Care Med 2018;44:281–299

Figure 1 (abstract P176) Percentage of perfused small vessels (PPVsmall) across time points (base = baseline; s = shock; r = resuscitation). Boxes show 25th to 75th percentile, line is median, whiskers extend to 1.5 × IQR. Outliers not shown

P177 Impact of vasopressor administration on peripheral perfusion assessed by temperature gradient during severe hemorrhagic shock

M Magnin

Agro Sup, Physiology/Pharmacology, Marcy L'Etoile, France

Critical Care 2026, 30 (Suppl 1): P177

Introduction: The use of vasopressors in hemorrhagic shock remains debated. They may help limit crystalloids and transfusion needs, but excessive vasoconstriction could impair tissue perfusion. We therefore assessed the impact of vasopressin and norepinephrine on peripheral perfusion, measured by temperature gradients, in a porcine model of severe hemorrhagic shock.

Methods: Hemorrhagic shock was induced by removing 35 mL/kg of blood over 1 h (T1) in 60- 65 kg pigs. After 1.5 h of untreated hypotension (T2), the control (C) group (n = 5) received boluses of whole blood and Ringer’s lactate. The vasopressin (V) group (n = 5) received vasopressin at 0.6 mU/kg/min, and the norepinephrine (N) group (n = 5) received 0.2 µg/kg/min, in addition to whole blood and Ringer’s lactate. Resuscitation targeted a mean arterial pressure of 65 mmHg, with a pre-specified plasma hemoglobin-based algorithm. The tarsus–abdomen temperature gradient (GTmean) was measured every 30 min using a thermal camera, calculated as mean abdominal temperature minus mean tarsal temperature. ΔGTmean was defined as the difference between each time point and the individual T2 value (before resuscitation). Linear mixed models were used for analysis.

Results: One pig in group C died before resuscitation. GTmean increased significantly before resuscitation (+ 3.8 °C, CI [2.9; 4.7]). GTmean profiles showed marked inter-individual variability (Figure, panel A). ΔGTmean decreased over time in the C and V groups (–0.0093 °C/min, CI [–0.0127; –0.0057] and –0.0078 °C/min, CI [–0.0109; –0.0046]), with no significant change in the N group (0.0000 °C/min, CI [–0.0033; 0.0032]) (Figure, panel B).

Conclusions: Vasopressin and control animals showed improving peripheral perfusion, whereas norepinephrine failed to reduce the temperature gradient during resuscitation.

Figure 1 (abstract P177) Temperature gradient in control (pink), noradrenaline (green), and vasopressin (blue) groups

P178 Elevated neutrophil-to-lymphocyte ratio as a biomarker of systemic stress complementing hemodynamic determinants of capillary refill time: a physiologic analysis in critical illness

C Michailides 1 , B Khaled Mohamed Sallam 1 , D Velissaris 2 , R Attou 1 , C Pierrakos 1 , MT Talpos 1

1 Brugmann University Hospital, Department of Intensive Care, Brussels, Belgium, 2 University Hospital of Patras, Department of Internal Medicine, Patras, Greece

Critical Care 2026, 30 (Suppl 1): P178.

Introduction: The interplay between macro-hemodynamic variables and catecholaminergic stress may contribute to CRT prolongation. The neutrophil-to-lymphocyte ratio (NLR) is a simple biomarker of stress and inflammation in critical illness. We conducted a physiological study to assess whether systemic stress (high NLR) influences CRT prolongation across distinct macro-hemodynamic states.

Methods: This prospective physiological study enrolled critically ill adults, for whom fingertip CRT was measured under controlled hemodynamic conditions and analyzed offline from standardized video recordings. Cardiac index (CI) and mean arterial pressure (MAP) were measured concomitantly using transthoracic echocardiography (cut-off 3 L/min/m 2 ) and an intra-arterial catheter (cut-off 70 mmHg). Routine early-morning blood samples provided NLR values (cut-off ≥ 7.2). Macro-hemodynamic phenotypes were defined by the four combinations of low/high CI and MAP. The primary endpoint was the Bayesian posterior probability of prolonged CRT (> 3 s) across NLR strata within each phenotype.

Results: 84 patients were evaluated, of whom 36 (43%) exhibited CRT ≥ 3 s. Compared with those with normal CRT, these patients showed lower CI (3.2 [2.5–3.6] vs 3.3 [2.8–4.1] L/min/m 2 ; SMD 0.26), lower MAP (76 [68–85] vs 86 [72–95] mmHg; SMD 0.41), and higher NLR (10.1 [4.1–17.5] vs 7.1 [4.4–11.3]; SMD 0.21). Bayesian modeling showed that the highest posterior probabilities of CRT > 3 s occurred in the Low CI/Low MAP phenotype (0.77–0.97). The intermediate phenotypes showed variable and overlapping probabilities, whereas the High CI/High MAP group had the lowest and most stable estimates. Within each hemodynamic phenotype, a high NLR produced an upward shifts in posterior probability (Figure).

Conclusions: CRT prolongation was predominantly linked to macro-hemodynamic impairment, whereas systemic stress assessed by NLR had a modest yet consistent influence across hemodynamic phenotypes.

Figure 1 (abstract P178) Bayesian analysis of the probability of CRT > 3 s across macro-hemodynamic phenotypes. Error bars represent 95% credible intervals

P179 How stable is capillary refill time? Assessing repeatability in critically ill patients

B Khaled Mohamed Sallam 1 , MT Talpos 1 , C Michailides 1 , D Velissaris 2 , R Attou 1 , C Pierrakos 1

1 Brugmann University Hospital, Department of Intensive Care, Brussels, Belgium, 2 University Hospital of Patras, Department of Internal Medicine, Patras, Greece

Critical Care 2026, 30 (Suppl 1): P179

Introduction: Capillary refill time (CRT) is a simple, bedside indicator of peripheral perfusion used to identify hypoperfusion in critically ill patients. Recently, CRT has been suggested as a monitoring tool to assess the effects of interventions aimed at enhancing perfusion. However, its natural variability and consistency in real-world conditions remain poorly established, which limits confidence in its use for continuous monitoring.

Methods: This prospective observational study measured critically ill patients’ fingertip CRT twice, 20 min apart, with no interventions in between. Each measurement was recorded on video and analyzed offline using a standardized digital workflow. The primary endpoint was the agreement between the first and second CRT readings, as evaluated using the two-way random-effects, absolute-agreement, single-measurement intraclass correlation coefficient (ICC[A,1]).

Results: 94 critically ill patients were enrolled; CRT could not be analyzed in 13 (14%) due to technical reasons. No significant difference was observed between baseline (2.7 [1.9–4.2] seconds) and control (3.2 [1.9–4.9] seconds, p = 0.08). Test–retest reliability was good (ICC[A,1] = 0.77; 95% CI, 0.68–0.84; p < 0.001; Figure), indicating consistent repeatability with limited residual variability, likely due to technical or physiological factors. The paired bootstrap-derived least significant change (LSC%) between repeated CRT measurements was 63% (95% CI 52–74%).

Conclusions: Measuring fingertip CRT at different times under pragmatic ICU conditions showed good reproducibility, supporting its use as a bedside monitoring tool. However, the notable variability observed in several cases suggests that significant changes only should be considered clinically meaningful when CRT is used to monitor patients in critical care.

Figure 1 (abstract P179) Scatter plot of repeated CRT values. Dashed red line: identity line

P180 Capillary refill time response to norepinephrine and vasopressin: benefit beyond cardiac output

RC Castro 1 , PM Mercado 2 , MA Amthauer 1 , VO Oviedo 1 , ED Valenzuela 1

1 Pontificia Universidad Catolica de Chile, Intensive Care Medicine, Santiago Centro, Chile, 2 Clinica Alemana, Intensive Care Unit, Santiago, Chile

Critical Care 2026, 30 (Suppl 1): P180

Introduction: Vasopressin (AVP) is often used cautiously as a second-line vasopressor because its predominantly vasoconstrictive action may reduce cardiac output (CO) despite increasing mean arterial pressure (MAP) [1]. Whether this hemodynamic profile translates into impaired tissue perfusion remains unclear. We aimed to compare the effects of norepinephrine (NE) and AVP on capillary refill time (CRT) and to relate these changes to CO and ventriculo–arterial (V–A) coupling during a standardized vasopressor test.

Methods: Thirty-two vasodilatory shock patients on NE underwent a vasopressor test (VPT) with either NE (n = 20) or AVP (n = 12) to increase MAP to 85 mmHg to improve perfusion. CRT, CO, heart rate, and indices of V–A coupling were assessed at baseline and after VPT (Figure). In the AVP group, patients were prespecified as afterload-sensitive or afterload-tolerant according to CO changes.

Results: In patients with NE only, V–A coupling and CO remained stable (CO ↑ in ~ 30%), with no group-level CRT change. AVP revealed two phenotypes: a) Afterload-sensitive (n = 4): ↑ Ea/Ees, ↓ CO, no CRT improvement; these patients had higher baseline CVP & mean systemic filling pressure (Pmsf). b) Afterload-tolerant (n = 8) showed stable CO and V–A coupling, with significant CRT shortening; these patients had lower baseline CVP & Pmsf, suggesting flow-independent perfusion improvement probably via restored vascular waterfall [2].

Conclusions: NE increased MAP without disturbing V–A coupling, preserving CO in a majority of patients with limited impact on CRT. AVP did not uniformly impair perfusion. When CO was preserved and CVP was low, CRT improved, likely reflecting microcirculatory benefit via improved pressure gradients (vascular waterfall) rather than increased flow. CRT identified afterload-tolerant vs afterload-sensitive phenotypes and may guide individualized AVP indication and vasopressor selection.

Acknowledgements: FONDECYT 1241463, 1250200

References Gordon AC et al. Chest 2012;142:593–605 Andrei S et al. Intensive Care Med Exp 2023;11:52

Figure 1 (abstract P180) Changes in cardiac output and capillary refill time in norepinephrine and vasopressin patients

P181 Early transport vs. on-scene resuscitation for refractory shockable rhythms: a nationwide time-dependent propensity matched study

SJ Ryu, YJ Seong, EJ Jung, SH Lee, YS Cho

Chonnam National University Hospital, Emergency Medicine, Gwangju, South Korea

Critical Care 2026, 30 (Suppl 1): P181

Introduction: For OHCA patients who remain in shockable rhythms after the first defibrillation, early transport may theoretically expedite access to hospital-based therapies. However, its benefit is uncertain in EMS systems without full ACLS capabilities. This study evaluated whether intra-arrest transport improves survival in refractory shockable OHCA where anti-arrhythmics and advanced defibrillation strategies are unavailable.

Methods: Data were derived from a nationwide OHCA registry between January 2015 and December 2022. Adult, non-traumatic OHCA patients with initial shockable rhythms who did not convert following the first defibrillation were included. Intra-arrest transport was evaluated using time-dependent propensity score matching to minimize resuscitation time bias. The primary endpoint was favorable neurological recovery at discharge. Risk ratios (RRs) with 95% confidence intervals (CIs) were estimated, and stratified assessments were performed by matched intervals after first defibrillation.

Results: Among 10,246 eligible patients, 8,131 received intra-arrest transport. After 1:1 time-dependent matching, 2,332 patients remained in each comparison arm. Neurological recovery rates were similar between the intra-arrest transport and on-scene resuscitation groups (11.7% vs. 11.5%; RR 0.97; 95% CI 0.91–1.07). However, transport initiated within 5 min after the first defibrillation was associated with worse neurological outcomes (RR 0.86; 95% CI 0.77–0.97).

Conclusions: In EMS systems lacking advanced prehospital interventions, intra-arrest transport does not improve neurological outcomes for OHCA patients who remain in refractory shockable rhythms despite initial defibrillation. Very early transport may be harmful, highlighting the importance of maintaining high-quality on-scene resuscitation before transfer. System-level strategies that strengthen both prehospital care and coordinated hospital management warrant further investigation.

P182 Combined insomnia and depression as a risk factor for OHCA: evidence from a multicenter case–control study

EJ Jung, YJ Seong, SH Lee, SJ Ryu, YS Cho

Chonnam National University Hospital, Emergency Medicine, Gwangju, South Korea

Critical Care 2026, 30 (Suppl 1): P182

Introduction: Insomnia and depression are well-recognized contributors to chronic disease and cardiovascular morbidity. However, their joint influence on the risk of out-of-hospital cardiac arrest (OHCA) has not been fully elucidated. This study examined whether insomnia is associated with OHCA incidence and whether its effect differs according to the presence of depression.

Methods: A prospective, multicenter case–control design was applied using data from the Phase II Cardiac Arrest Pursuit Trial with Unique Registration and Epidemiology Surveillance (CAPTURES-II) project, which included OHCA patients and matched community controls in Korea. The primary exposure was a documented history of insomnia. Conditional logistic regression models were used to evaluate OHCA risk associated with insomnia, and interaction analyses were performed to determine whether depression modified this relationship. Additionally, subgroup analyses were conducted among individuals with insomnia based on their medication status.

Results: A history of insomnia alone was not associated with an increased risk of OHCA (adjusted odds ratio [AOR] 0.95; 95% CI 0.64–1.40). However, a significant interaction was observed in younger participants: those with both insomnia and depression demonstrated a markedly elevated risk of OHCA (AOR 3.65; 95% CI 1.29–10.33), whereas patients with insomnia without depression did not show increased risk (AOR 0.84; 95% CI 0.59–1.17). In subgroup analyses, depression increased OHCA risk only among patients with insomnia who were not taking sleep-related medications (AOR 3.66; 95% CI 1.15–11.66).

Conclusions: Comorbid insomnia and depression significantly heighten the risk of OHCA in younger individuals, while insomnia alone does not. The elevated risk was confined to patients not receiving pharmacologic treatment for insomnia, suggesting that early recognition and adequate management of sleep disorders may help reduce the likelihood of sudden cardiac arrest.

P185 Hemoperitoneum and cardiac arrest: diagnostic challenges following prolonged resuscitation

AR Branco, P Coelho, I Lima Freitas, L Costeira, A Colmente, R Passos, R Corga Silva

ULSAM, SMI, Viana do Castelo, Portugal

Critical Care 2026, 30 (Suppl 1): P185

Introduction: Managing a patient during and after cardiac arrest (CA) presents significant challenges, as a myriad of factors contributes to the overall patient outcome. Post-resuscitation management focuses on identifying and managing multiorgan dysfunction resulting from the ischemic events and/or the cardiopulmonary resuscitation (CPR) maneuvers. Although abdominal injuries in cardiac arrest are rare, abdominal trauma related to resuscitation maneuvers is recognized as a potential complication needed to be considered in patients with rapidly worsening cardiovascular dysfunction [1].

Methods: We present two cases of CA in which identification of hemoperitoneum was essential for optimizing outcomes.

A) 46 y.o. woman suffered a non-traumatic CA in which rhythm remained shockable, supporting a primary dysrhythmic etiology. Early whole-body computed tomography revealed hemoperitoneum. With progressive cardiovascular decline, an urgent laparotomy identified and controlled hepatic lacerations, resulting in significant cardiovascular improvement.

B) 50 y.o. woman had a non-traumatic CA with persistent pulseless electrical activity. Fibrinolytic therapy for suspected pulmonary embolism was given during 32 min of CPR, restoring circulation. She then developed hemorrhagic shock and imaging showed liver and spleen lacerations with active bleeding. Urgent surgery controlled the hemorrhage and improved her outcome.

Results: Discerning whether the hemoperitoneum resulted from resuscitation efforts or constituted the primary cause of arrest due to hemorrhagic shock, remains challenging.

Conclusions: Patient prognosis following CA is influenced by multiple factors. Resuscitation-related injuries are an accepted risk in emergency settings, prolonged CPR requires active evaluation for potential complications. The two cases are particularly relevant as they show how it’s challenging to determine whether the hemorrhage was the precipitating cause of the arrest or a consequence of CPR.

Acknowledgement: Written consent to publish was received from the patients.

Reference Farbu BH et al. PLoS One 2025;20:e0329164

P186 Effects of inspiratory pressures in chest compression synchronized ventilation with arterial blood gases and lung trauma in experimental cardiac arrest

R Östman 1 , J Kopra 1 , A Heino 2 , L Mehtonen 3 , M Laitinen 4 , E Litonius 5 , O Arvola 5 , JA Heinonen 6 , MB Skrifvars 1 , PT Pekkarinen 5

1 University of Helsinki and Helsinki University Hospital, Department of Emergency Care and Services, Helsinki, Finland, 2 University of Helsinki and Helsinki University Hospital, Helsinki, Finland, 3 University of Latvia, Riga, Latvia, 4 VetCT Teleconsulting – Teleradiology Small Animal Team, Helsinki, Finland, 5 University of Helsinki and Helsinki University Hospital, Division of Anaesthesiology, Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki, Finland, 6 PäijätHäme Central Hospital, Department of Anaesthesiology and Intensive Care Medicine, and Centre for Prehospital Emergency Care and Emergency Medicine, Lahti, Finland

Critical Care 2026, 30 (Suppl 1): P186

Introduction: Chest compression synchronized ventilation (CCSV) is a novel ventilation strategy, which may improve arterial oxygenation during cardiopulmonary resuscitation (CPR). Our previous study raised a safety concern due to more pneumothoraces in the CCSV group compared to manual asynchronous ventilation. To study this further, we performed a new study including an additional group with lower inspiratory pressure in CCSV.

Methods: We randomized 36 pigs into 3 groups: CCSV with 40 mbar or 60 mbar inspiratory pressure (CCSV40, CCSV60) and manual asynchronous ventilation (MAV). A MEDUMAT Standard2 ventilator was used to provide CCSV. Chest compressions were performed with a Lucas® 2 device. Arterial samples were drawn every 5 min and monitoring was recorded continuously. Post-mortem chest CT scans were used to assess lung trauma.

Results: The median intra-arrest arterial blood gas results for CCSV40 were PaO 2 = 131.5 (105.4 – 155.7) mmHg, PaCO 2 = 46.14 (41.8 – 57.6) mmHg and pH = 7.23 (7.13 – 7.26). In the CCSV60 group PaO 2 = 407.4 (291.1 – 498.3) mmHg, PaCO 2 = 23.4 (17.5 – 28.1) mmHg and pH = 7.49 (7.44 – 7.52). In the manual ventilation group PaO 2 = 120.9 (99.5 – 143.3) mmHg, PaCO 2 = 46.6 (41.0 – 50.8) mmHg and pH = 7.26 (7.20 – 7.36). The results showed higher oxygenation ( p = 0.0002), lower CO 2 ( p = 0.0005) and higher pH ( p = 0.0486) in the CCSV60 group when compared with a linear mixed model. The number of pneumothoraxes were (none/mild/moderate/severe) MAV = 3/7/2/0, CCSV40 = 5/0/2/5, CCSV60 = 3/0/3/6. Difference in severity was analyzed with Fisher’s exact test ( p = 0.0013).

Conclusions: This study shows that PO 2 , CO 2 and pH were superior with CCSV60, CCSV40 did not show benefits compared to MAV. The severity of pneumothorax was greater with increasing inspiratory pressures.

P187 Beyond the chain of survival: a scoping review of artificial intelligence use in cardiac arrest

X Luo, FR Lin, T Huang, JZ Zhang, AQ Lao, ZF Yang

Sun Yatsen Memorial Hospital, Sun Yatsen University, Intensive Care Unit, Guangzhou, China

Critical Care 2026, 30 (Suppl 1): P187

Introduction: Cardiac arrest (CA) is a critical global health emergency requiring immediate intervention. While recent studies have explored leveraging artificial intelligence (AI) to improve CA outcomes, notable deficiencies remain in the discourse regarding systematic evidence. Therefore this scoping review provides a comprehensive analysis of the landscape of AI applications in CA.

Methods: We conducted comprehensive searches in Pubmed, the Cochrane Library, Web of Science and Embase from database inception to 10 June 2025. We included studies that applied AI within in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA) populations across these domains: predicting CA occurrence, prognosing CA outcomes, utilizing large language models (LLMs), and assessing cardiopulmonary resuscitation (CPR) and other applications of AI to CA. We extracted study details, data sources, population characteristics, AI models, and results onto study-specific forms.

Results: We conducted comprehensive searches in Pubmed, the Cochrane Library, Web of Science and Embase from database inception to 10 June 2025. We included studies that applied AI within in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA) populations across these domains: predicting CA occurrence, prognosing CA outcomes, utilizing large language models (LLMs), and assessing cardiopulmonary resuscitation (CPR) and other applications of AI to CA. We extracted study details, data sources, population characteristics, AI models, and results onto study-specific forms.

Conclusions: We comprehensively summarized the current research on AI applications in CA in our review, demonstrating its validated utility across pre-arrest prediction, real-time rhythm analysis, CPR optimization, defibrillation guidance, and prognosing post-return of spontaneous circulation (ROSC) outcome (Figure). Furthermore this study indicates future research directions. AI reveals unique insights that could greatly benefit clinical practice.

Figure 1 (abstract P187) Artificial-intelligence-enabled support throughout the cardiac arrest care continuum

P188 Keeping cool? A reality check on post-ROSC TTM

C Thornton, AR Fennessy, J Bates

University Hospital Galway, Department of Intensive Care, Galway, Ireland

Critical Care 2026, 30 (Suppl 1): P188

Introduction: Targeted temperature management (TTM) is a core recommendation by the European Resuscitation Council (ERC) for post-return of spontaneous circulation (ROSC) care. ERC guidelines (2021) advise maintaining a core temperature between 32–36 °C for at least 24 h and < 37.7 °C for 72 h post ROSC. Continuous, accurate, and consistent temperature measurement is essential to achieve these recommendations. This audit evaluated adherence to TTM temperature targets, duration and frequency of monitoring, and methods used in patients who suffered an out-of-hospital cardiac arrest (OOHCA) who survived to ICU admission.

Methods: A retrospective audit of temperature management in all patients surviving to ICU admission in University Hospital Galway post OOHCA with ROSC during 2024 was conducted. Data collated included temperature readings, methods of measurement, total monitoring duration, and ICU length of stay. Compliance with ERC 2021 guidelines was assessed.

Results: Twenty-two patients were included. No patient had reliable documentation confirming maintenance of a target temperature of 32–36 °C for ≥ 24 h (Figure). Two patients appeared compliant, although documentation was incomplete. Eleven patients did not exceed 37.7 °C during their monitoring period; however, no patient had monitoring beyond 63 h. Median monitoring duration was 48 h (IQR 33–49.5). No patient received hourly or consistently timed measurements. Data quality was limited by variability in both frequency and modality of measurement.

Conclusions: Delivery and documentation of TTM in this cohort were suboptimal. Key deficiencies included inadequate monitoring duration, lack of sustained temperature control within therapeutic targets, inconsistent measurement frequency, and non-standardised techniques. These findings support the introduction of a new departmental protocol for TTM post-ROSC to include core temperature monitoring, unified modality per patient, and structured 72-h monitoring protocols.

Figure 1 (abstract P188) Scatter Plot depicting proportion of temperature readings within target range (32-36C) during the first 24 h post-ROSC in patients admitted to ICU following OHCA Note: Data from Patients 1, 4, 11, 14, 17, and 20 omitted due to lack of data on temperature measurement due to a) time temperature measured < 24h or b) lack of temperature measurements over the first 24h post-ROSC

P189 Timing of hypothermic temperature control does not affect neurological outcomes after cardiac arrest: a systematic review and meta-analysis

K Csokekabai 1 , Z Molnár 2 , L Zubek 2 , P Hegyi 3 , G Nagy 4 , EH Kovács 1 , Z Sipos 1 , D Laczkó 5 , C Turan 2 , K Tánczos 2

1 Semmelweis University, Centre for Translational Medicine, Budapest, Hungary, 2 Semmelweis University, Department of Anaesthesiology and Intensive Therapy, Budapest, Hungary, 3 Semmelweis University, Institute of Pancreatic Diseases, Budapest, Hungary, 4 Semmelweis University, Department of Emergency Medicine, Budapest, Hungary, 5 Semmelweis University, Department of Interventional Radiology, Városmajori Heart and Vascular Centre, Budapest, Hungary

Critical Care 2026, 30 (Suppl 1): P189

Introduction: Out-of-hospital cardiac arrest is associated with a low rate of favourable neurological recovery, estimated at 8%. Lowering the cerebral metabolic rate with hypothermia is hypothesized to improve this outcome. Since in-hospital temperature control is recommended to start as early as possible, we investigated whether initiating earlier hypothermic temperature control in the prehospital setting could further enhance neurological recovery.

Methods: A pre-registered systematic search (PROSPERO: CRD42024601051) was run in PubMed, Embase and Cochrane Central on November 3, 2024, to identify randomised controlled trials that compare prehospital vs. in-hospital initiation of hypothermic temperature control of out-of-hospital cardiac arrest patients. The Cochrane Handbook was followed for data extraction and synthesis. The RoB 2 tool was used for risk of bias assessment. The meta-analyses were conducted using a random-effects model.

Results: A total of 7117 articles were screened, and 7 studies were selected for the analysis containing the data of 3288 patients. The intervention group achieved the target temperature of 33 °C significantly earlier (MD: -97.27 min; 95% CI: -139.46 to -55.08; p = 0.010). In the intervention group, no significant difference was observed in the odds for favourable neurology (OR: 0.98; 95% CI: 0.80–1.22, p = 0.855) (Figure). The odds for recurrent cardiac arrest and pulmonary oedema were significantly higher in the intervention group (OR: 1.33; 95% CI: 1.20–1.47; p = 0.009 and OR: 1.66; 95% CI: 1.24–2.23; p = 0.001).

Conclusions: Despite reaching the target temperature significantly earlier, prehospital initiation of hypothermic temperature control did not improve favourable neurological recovery compared to in-hospital initiation. Furthermore, early initiation also significantly increased the odds for recurrent cardiac arrest and pulmonary oedema. Therefore, these findings do not support the implementation of prehospital hypothermic temperature control in out-of-hospital cardiac arrest.

Figure 1 (abstract P189) Forest plot demonstrating no statistically significant difference in odds of favorable neurological outcome at hospital discharge between early (prehospital) initiated cooling and in-hospital initiated cooling. OR = odds ratio; CI = confidence interval

P190 Application of a frontal electroencephalogram for rapid neurological prognostication by ICU nurses in cardiac arrest patients (FRONT study); an implementation study

I Van de Pol 1 , AJ Court 2 , J Van Helden 1 , A Seeber 2 , E Scholten 1 , V Lagerberg 3 , HS Moeniralam 1 , L Schoonhoven 4 , D Stalpers 4 , L Wieske 2

1 St. Antonius Ziekenhuis, Intensive Care Unit, Nieuwegein, Netherlands, 2 St. Antonius Ziekenhuis, Clinical Neurophysiology, Nieuwegein, Netherlands, 3 St. Antonius Ziekenhuis, Medical Physics and Instrumentation, Nieuwegein, Netherlands, 4 UMCU, General Practice Nursing Science, Utrecht, Netherlands

Critical Care 2026, 30 (Suppl 1): P190

Introduction: Continuous electroencephalography (cEEG) is a valuable tool for neurological prognostication after cardiac arrest. However, limited availability of EEG technicians and time-consuming electrode placement delay early registration. Self-adhesive electrodes in a 6-electrode frontal (fEEG) configuration have been shown to be a reliable alternative and could allow ICU nurses to start registrations early. This study investigated implementation of fEEG applied by nurses within three hours after ICU admission in cardiac arrest patients.

Methods: The FRONT study followed a type 3 hybrid design. Nurses were trained to start an fEEG through a theoretical and practical session and were supported by a Step-by-Step interactive guide. Knowledge, attitude, and practice (KAP) surveys were completed by nurses after the training and after the application of each fEEG. Effectiveness was measured prospectively in 60 patients by assessing whether fEEG was successfully applied.

Results: The response rate was 46% (49/107) after training and 68% (41/60) post-application. Most nurses (84%) indicated that they had sufficient knowledge about fEEG electrodes placement and monitoring. The interactive guide was frequently (98%) used during fEEG initiation; median application time was 20 min [IQR: 15–25]. All nurses found early EEG monitoring to be meaningful; perception improved since before implementation (3.98 + -0.78 vs 4.54 + -0.50, p < 0.001). An fEEG was applied in 88% of patients (53/60), including 73% (44/60) within 3 h. Correct fEEG electrode placement was confirmed by an EEG technician in all patients.

Conclusions: Nurses are able to start fEEG registrations in nearly all patients within three hours after ICU admission, using a short and multifaceted training program in combination with an online Step-by-Step interactive guide. Addressing the value of early EEG monitoring in the training program may help to prevent resistance to this task by ICU nurses. Further research is needed on the interpretability of the fEEG.

P191 Optimising EEG acquisition for neuroprognostication after cardiac arrest: a systematic review

A Binuraj, O Reeves-Chen, M De Silva-Morgan, C Chacko, T Veenith

New Cross Hospital, Intensive Care, Wolverhampton, UK

Critical Care 2026, 30 (Suppl 1): P191

Introduction: Accurate neuroprognostication after cardiac arrest requires EEG recordings that are not limited by sedation, artefact, or technical factors. This systematic review assessed approaches that improve EEG quality to support reliable prognostic interpretation [1].

Methods: A structured literature search identified studies describing technical and clinical strategies to optimise EEG acquisition. Evidence relating to sedation washout, artefact reduction, electrode placement, reactivity testing, seizure control, and recording timing was synthesised. Relevant guidelines were included for alignment with current prognostication frameworks [2].

Results: Key practices consistently improved EEG interpretability. Sedation washout, particularly of propofol and long-acting opioids, reduced drug-induced suppression that may mimic malignant patterns [3]. Good electrode placement and low impedance improved background assessment. Early EEG after ROSC aided evaluation of continuity. Muscle artefact frequently obscured cortical activity; short-acting neuromuscular blockers improved signal clarity when needed. Standardised stimulation better identified EEG reactivity, while continuous EEG allowed detection of seizures and evolving abnormalities. Integrating EEG findings with clinical examination and imaging strengthened overall prognostic confidence (Figure).

Conclusions: Structured management of sedation, artefact, electrode technique and stimulation protocols enhances EEG quality after cardiac arrest. These measures support clearer pattern classification and more reliable multimodal neuroprognostication.

References Hirsch LJ et al. J Clin Neurophysiol 2021;38:1–29 Sandroni C et al. 2020;182:109637 Westhall E et al. Neurology 2016;86:1482–1490

Figure 1 (abstract P191) Stepwise integration of EEG into multimodal neurological prognostication after cardiac arrest: minimising confounders and artefact to improve prognostic accuracy

P192 Achieving optimal EEG quality for neuroprognostication after cardiac arrest: a structured confounder-elimination protocol

O Reeve-Chen, M De Silva-Morgan, A Binuraj, T Veenith, C Chacko

The Royal Wolverhampton NHS Trust, Intensive Care, Wolverhampton, UK

Critical Care 2026, 30 (Suppl 1): P192

Introduction: Electroencephalography (EEG) is key in multimodal neuroprognostication in comatose survivors of cardiac arrest, but accuracy is limited by heterogeneity in EEG timing, inconsistent terminology, and confounders such as sedation or artefact. Standardised ACNS criteria and improved acquisition methods aim to enhance reliability. This review synthesises current evidence to evaluate EEG performance, confounders, and optimal integration into prognostic pathways [1].

Methods: A qualitative synthesis of studies from 2015–2026 was performed, assessing prognostic accuracy of malignant, benign, and reactive EEG patterns, alongside the influence of targeted temperature management, sedation, aetiology, and artefact-limiting strategies on interpretability [1].

Results: Highly malignant EEG patterns—suppression and burst-suppression ≥ 24 h post-ROSC—retain very high specificity (93–100%) but low sensitivity (~ 50%), making them useful “rule-in” markers rather than standalone predictors. Benign patterns, especially early continuous and reactive backgrounds, strongly indicate favourable outcome [3]. Reactivity adds further prognostic value. Sedation and hypothermia can alter appearance but rarely reduce specificity. Artefact remains a major source of error, with neuromuscular blockade improving clarity when EMG interference dominates. Malignant-pattern specificity decreases in non-anoxic coma, underscoring the importance of clinical context (Figure).

Conclusions: EEG provides critical insight into hypoxic–ischaemic brain injury and is a powerful prognostic tool when acquired early, interpreted with ACNS criteria, and integrated within guideline-mandated multimodal frameworks. Optimisation of EEG quality—via sedation washout protocols, standardised reactivity testing, and artefact reduction—substantially enhances diagnostic confidence. Emerging quantitative EEG and machine-learning approaches offer promising avenues to reduce the persistent “indeterminate” prognostic gap.

References Sandroni C et al. Intensive Care Med 2020;46:1803–1851 Hirsch LJ et al. J Clin Neurophysiol 2021;38:1–29 Westhall E et al. Neurology 2016;86:1482–1490

Figure 1 (abstract P192) Staged protocol to improve EEG quality and interpretability after cardiac arrest

P194 Evaluating the safety of valproic acid in the traumatic brain injury population

AE Johnson, RM Nelson, TS Lam, JT Jancik

Hennepin Healthcare, Pharmacy, Minneapolis, USA

Critical Care 2026, 30 (Suppl 1): P194

Introduction: A 1999 study by Temkin et al. suggested a trend towards higher mortality in patients with traumatic brain injuries (TBI) on prophylactic valproic acid (VPA) compared to phenytoin [1]. Because of this incidental finding, subsequent guidelines discouraged VPA use for seizure prophylaxis in TBI patients [2]. There is currently no guidance for the use of VPA for agitation management in the TBI population. This study aimed to evaluate the safety of VPA in TBI patients when used for agitation.

Methods: This single-center, retrospective study compared mortality at up to 2 years between TBI patients who received at least 48 h of VPA between 1/1/2019 and 22/10/2023 to a historical control of TBI patients admitted between 1/1/2015 and 31/12/2018. Secondary outcomes in the VPA group included incidence of hepatotoxicity, hyperammonemia, thrombocytopenia, and free or total VPA levels above the upper limit of normal.

Results: The 73 encounters in the treatment group were matched by Injury Severity Score, age, and sex to 73 control encounters. A Kaplan–Meier survival analysis showed mortality rates at up to 2 years were not significantly different between VPA treatment and control groups ( p = 0.836). The median starting and maximum dose of VPA was 20.2 (IQR 15.8–25.9) and 27.7 (IQR 23.3–34.2) mg/kg/day, respectively. The incidences of VPA-related safety outcomes can be found in the Figure.

Conclusions: Patients with TBIs who were initiated on VPA for agitation management had similar mortality rates at up to 2 years compared to a historical control. Valproic acid was generally well tolerated.

References Temkin N et al. N Engl J Med 1999;323:497–502 American College of Surgeons. Traumatic Brain Injury Best Practice Guidelines, 2024

Figure 1 (abstract P194) Incidences of VPA-related safety outcomes. (1) Encounters with monitoring available (2) AST or ALT > 3 times the upper limit of normal or doubling from baseline after VPA initiation if above normal limits on admission (3) Ammonia > 60 µmol/L after VPA initiation (4) Platelets decrease to < 150 × 10 3 /µL after VPA initiation or decrease by > 50% after VPA initiation if platelets already < 150 × 10 3 /µL

P195 Association between hyperosmolar therapy and ICU mortality in patients with moderate to severe traumatic brain injury without pupillary abnormality: a propensity score-matched cohort study from the TraumaBase® registry

M Lamamri 1 , JD Moyer 2 , T Geeraerts 3 , T Botrel 4 , M Werner 5 , M Leone 6 , E Weiss 1 , A Codorniu 1 , Traumabase Group 7

1 Assistance Publique des Hôpitaux de Paris Hôpital Beaujon, Réanimation Chirurgicale, Clichy, France, 2 CHU Caen, Réanimation Chirurgicale, Caen, France, 3 CHU Toulouse, Réanimation Chirurgicale, Toulouse, France, 4 Assistance Publique des Hôpitaux de Paris Hôpital Pitié, Réanimation Chirurgicale, Paris, France, 5 Assistance Publique des Hôpitaux de Paris Hôpital Kremlin-Bicètre, Réanimation Chirurgicale, Paris, France, 6 Assistance Publique des Hôpitaux de Marseille APHM Nord, Réanimation Chirurgicale, Marseille, France, 7 Assistance Publique des Hôpitaux de Paris Hôpital Beaujon, Clichy, France

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Introduction: Evidence remains scarce regarding the clinical benefit of hyperosmolar therapy and its effect on outcomes in TBI patients without pupillary abnormality during the prehospital phase [1,2]. The aim of this study is to assess the association between hyperosmolar therapy and ICU mortality in TBI patients without pupillary abnormality.

Methods: We conducted a multicentric retrospective study using data from a national registry across 20 Level 1 Trauma Centers from 2015 to 2025 in France. We performed propensity score matching on selected variables [i.e. age, sex, initial Glasgow, center, Abbreviated Injury Scale head, Simplified Acute Physiology Score II, prehospital systolic blood pressure, CT before hospital admission] with a ratio of 1:2. The primary outcome was ICU mortality. Hemorrhagic shock was defined as receiving at least 4 packed red blood cells transfusions within the first 6 h of management or requiring immediate hemostatic surgery or interventional radiology before whole-body computed tomography scan.

Results: We included 858 patients: after matching, no significant differences were observed between the two groups regarding baseline demographic characteristics and the mechanism of TBI (Table). No significant difference was observed in the need of neurosurgery within 24 h between hyperosmolar therapy group (20%, n = 56) and control group (15.2%, n = 85; p = 0.079). ICU mortality was higher in hyperosmolar therapy group (28.6%, n = 79) compared to control group (22.2%, n = 124; p = 0.049).

Conclusions: In this propensity score-matched cohort, the administration of hyperosmolar therapy during the prehospital phase was associated with a higher ICU mortality in TBI patients without pupillary abnormality.

References Carney N et al. Neurosurgery 2017;80:6–15 Eskandari et al. J Neurosurg 2013;119:338–346

Table (abstract P195) Baseline characteristics and initial management of patients ISS = Injury Severity Score; ICP = intracranial pressure; WLST = Withdrawal of Life-Sustaining Treatment.

P196 A protocol for studying consciousness in the intensive care unit

A Addis 1 , V D´Ambrosio 2 , P Mangili 1 , L Stanzani 3 , P Spiandorello 1 , M Baggiani 1 , A Guglielmi 4 , G Citerio 2

1 IRCCS Fondazione San Gerardo dei Tintori, Neurointensive Care Unit, Monza, Italy, 2 University of MilanoBicocca, School of Medicine, Milan, Italy, 3 IRCCS Fondazione San Gerardo dei Tintori, Neurology, Monza, Italy, 4 Alma Mater Ticinensis Foundation, Progetto Professionalità, Pavia, Italy

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Introduction: Consciousness is thought to depend on differentiation of brain activity and integration of distributed neural populations. EEG-based protocols that quantify signal complexity and large-scale connectivity are being developed with high-density recordings. In the ICU, high-density EEG is rarely available, yet identifying markers of emerging consciousness could improve prognostication and decisions about treatment intensity.

Methods: We aimed to develop an EEG analysis protocol to characterize thalamo-cortical dynamics and cortico-cortical connectivity in subacute disorders of consciousness (DoC) patients at the bedside in the NeuroICU.

Results: Patients with subacute DoC admitted to the NeuroICU underwent EEG recording using a reduced longitudinal montage. Recordings were exported to EDF, visually inspected to remove major artifacts, and contiguous epochs of at least 5 min were manually selected. Data were cleaned with an ASR-ICA pipeline and then processed in Python for quantitative analysis. We assessed thalamo-cortical dynamics by computing power spectra with a multitaper method and visually classifying them according to the ABCD model [1]. Cortico-cortical interactions were evaluated by computing two complexity metrics (Kolmogorov and Lempel–Ziv), permutation entropy in the alpha and theta bands, sample entropy, and three connectivity metrics: Granger causality and weighted Symbolic Mutual Information for unidirectional and bidirectional connectivity, and the Phase Lag Index.

Conclusions: We present a practical, bedside-compatible EEG protocol that integrates ABCD spectral classification with complementary complexity and connectivity measures in patients with subacute disorders of consciousness (Figure). We plan to implement this framework in a prospective data collection protocol to enable future validation studies linking EEG markers to clinical trajectories and outcomes.

Reference Schiff ND. Press Médicale 2023;52:104161

Figure 1 (abstract P196) Application of the protocol in a patient in a minimally conscious state (MCS) secondary to traumatic brain injury (TBI) at two time points (panels A and B). Top row: measures of cortico-cortical complexity and connectivity. Middle row: spectral plot for ABCD classification of thalamo-cortical connectivity. Bottom row: MRI showing bihemispheric, callosal, and upper mesencephalic traumatic axonal injury

P197 Investigation into the role and mechanism of heparanase inhibition in sepsis-associated blood–brain barrier damage

HS Zhang, YX Li, XX Wang, L Zhang

Xiangya Hospital of Central South University, Changsha, China

Critical Care 2026, 30 (Suppl 1): P197

Introduction: Blood–brain barrier (BBB) injury is a primary pathological event in sepsis-associated encephalopathy (SAE). Heparanase (HPSE), the key enzyme degrading heparan sulfate (HS) proteoglycans in the endothelial glycocalyx, is upregulated early in sepsis and exacerbates BBB disruption. This study evaluated whether pharmacological or genetic inhibition of HPSE mitigates SAE by protecting BBB integrity.

Methods: LPS-induced BBB injury models in HUVECs and P-BMECs (cellular) and endotoxemia/CLP mice (animal). Interventions: HPSE inhibitors (heparin, SDX, fucoidan, OGT2115) and HPSE-/- knockout. Assessments: functional BBB damage (live imaging, Evans blue, Transwell); structural damage (CCK-8, LDH, WB/IF); SAE severity (survival, behavior, Nissl staining). Mechanism: pyroptosis agonists and AAV-X1.1-mediated HPSE restoration in BMECs for rescue.

Results: In cellular models and animal models, LPS stimulation significantly increased HPSE expression and HS degradation. HPSE inhibitors could effectively reduced BBB hyperpermeability. Structurally, inhibitors preserved cell viability, reduced LDH release, and maintained tight junction proteins (Claudin-5, ZO-1). In vivo, all inhibitors improved survival post-endotoxemia. Behavioral tests revealed enhanced performance with heparin and fucoidan yielding the most consistent benefits. HPSE knockout (HPSE-/-) mice and derived BMECs confirmed these protective effects. Mechanistically, HPSE inhibition reduced pyroptosis-related proteins (Caspase-4/11, N-GSDMD) in endothelial cells. Pyroptosis agonists reversed BBB protection, indicating HPSE acts via promoting pyroptosis. Endothelial-specific HPSE restoration in HPSE-/- mice partially reinstated BBB dysfunction and pyroptosis, identifying BMECs as a critical source of pathogenic HPSE.

Conclusions: HPSE inhibition alleviates SAE by preserving BBB integrity, largely through suppressing pyroptosis in BMECs, highlighting HPSE as a promising therapeutic target.

P199 Beyond recanalization: early organ-support profile and outcomes after mechanical thrombectomy for proximal ischemic stroke in Bogotá, Colombia

MC Niño de Mejia 1 , D Cohen 1 , MF Parada 1 , A Romero 1 , JA Mejia 2 , C Martinez 3

1 Hospital Universitario Fundacion Santa Fe de Bogota, Anestesiologia, Bogotá, Colombia, 2 Hospital Universitario Fundacion Santa Fe de Bogota, Neuroradiologia Intervencionista, Bogotá, Colombia, 3 Hospital Universitario Fundacion Santa Fe de Bogota, Neurologia, Bogotá, Colombia

Critical Care 2026, 30 (Suppl 1): P199

Introduction: Mechanical thrombectomy (MT) achieves high recanalization rates in proximal ischemic stroke (PIS), but many critically ill patients treated in the ICU remain dead or severely disabled. We evaluated whether simple periprocedural variables define a high-risk profile after MT.

Methods: Retrospective single-centre cohort of adults undergoing MT for PIS (2019–2023) in a Joint Commission International–accredited stroke centre in Bogotá Colombia. We collected demographics, NIHSS, vessel territory, TICI, number of passes, anaesthetic technique, haemodynamic monitoring, vasopressor use and postoperative mechanical ventilation (MV). Outcomes were 90-day modified Rankin Scale (mRS), disability (mRS 0–2, 3–5, 6) and mortality.

Results: Fifty-eight patients were included (59% male, mean age 66 years, median NIHSS 16.5); 90% had anterior circulation stroke and 86% achieved TICI 2b–3. Despite this, 53% died by day 90 and only 26% achieved mRS 0–2. Higher baseline NIHSS was associated with worse 90-day mRS ( p = 0.001). A greater number of device passes was associated with both disability and mortality ( p ≤ 0.03). Postoperative MV was strongly associated with disability and death ( p = 0.001), while vasopressor support was associated with greater disability ( p = 0.002) but not mortality. No signal was observed for anaesthetic technique or neuromonitoring (BIS, NIRS) on outcome (Table).

Conclusions: In this MT cohort, a very good angiographic reperfusion did not translate into survival or functional independence. A simple early profile combining severe stroke (high NIHSS), difficult thrombectomy (multiple passes) and need for perioperative MV identified a critically ill MT phenotype with dismal prognosis. Identifying this group would highlight the need to intensify compliance with perioperative hemodynamic and MV targets and to select patients for trials aimed at bridging the gap between recanalization and recovery.

Table (abstract P199) Early organ-support profile

P200 Not all bradycardias are the same: trigeminocardiac reflex, brainstem stimulation and anesthetic vagotonia during brain tumor surgery

MC Niño de Mejia, D Cohen, MF Parada, A Romero

Hospital Universitario Fundacion Santa Fe de Bogota, Anestesiologia, Bogotá, Colombia

Critical Care 2026, 30 (Suppl 1): P200

Introduction: Severe intraoperative bradycardia is a relevant hemodynamic event in brain tumor surgery. It may arise from three main mechanisms: activation of the trigeminocardiac reflex (TCR) during manipulation of trigeminally innervated dura or cortex, direct stimulation of brainstem vagal centers, and vagotonia related to anesthetic drugs. This study describes the incidence, causes and surgical distribution of bradycardia in supratentorial and infratentorial tumor resections.

Methods: We conducted a retrospective observational study of adult patients who underwent brain tumor surgery. 1020 supratentorial and 126 infratentorial procedures were performed. Bradycardia was defined as heart rate < 40 beats per minute requiring intervention. Variables included overall incidence, etiological mechanism, surgical region and approach.

Results: Severe bradycardia occurred in 37 patients. In supratentorial surgery, 80.7% of episodes were related to vagotonia secondary to anesthetic drugs and/or other cardiovascular mechanisms such as TCR. In infratentorial surgery, brainstem-mediated mechanisms caused 54.5%. Parasagittal and temporal craniotomies were most frequently associated with TCR (Table).

Conclusions: Although infrequent, requires close hemodynamic monitoring and mechanism-directed treatment. Supratentorial procedures were mainly associated with TCR and anesthetic-induced vagotonia, whereas infratentorial surgery showed a predominance of brainstem-mediated bradycardia. This pattern may help anesthesiologists anticipate and tailor therapy: TCR- or anesthetic-related bradycardia typically responds to anticholinergic drugs, whereas brainstem-mediated bradycardia should not be treated with anticholinergics and is best managed by immediately alerting the surgeon and stopping the surgical stimulus to preserve brainstem reflex monitoring.

Table (abstract P200) Distribution of intraoperative bradycardia by region and etiology.

P201 Does temporary aneurysm clipping matter? Association with postoperative cerebral edema in a surgical cohort

MC Niño de Mejia, D Cohen, MF Parada, A Romero

Hospital Universitario Fundacion Santa Fe de Bogota, Anestesiologia, Bogotá, Colombia

Critical Care 2026, 30 (Suppl 1): P201

Introduction: Temporary arterial clipping (TAC) is a fundamental technique in intracranial aneurysm surgery, used to create a bloodless surgical field and reduce the risk of intraoperative rupture (IOR), decreasing IOR from 26 to 8% in some reports. However, its impact on neurological outcome remains controversial.

Methods: We performed a retrospective study of 101 patients with cerebral aneurysms treated with surgical clipping between 2017 and 2025 at a tertiary center (Figure). Postoperative cerebral edema was assessed intraoperatively. Variables included age, vascular territory, TAC duration and type of anesthesia. Logistic regression assessed TAC–edema associations, and a binomial test examined whether TAC exposure among patients with edema exceeded that expected by chance.

Results: Edema occurred in 31 patients. TAC use was strongly associated with edema (OR 5.17; RR 2.23); 70% of patients in the TAC group developed edema, compared with 31.6% without TAC. Chi-square ( p = 0.00024) and Fisher’s exact tests ( p = 0.00013) confirmed this association. TAC is mainly linked to ischemia due to flow interruption, while prolonged ischemia and reperfusion may trigger cytotoxic and vasogenic edema. Evidence addresses ischemia, IOR and delayed vasospasm; the relationship with early cerebral edema remains underexplored. Although TAC duration < 20 min is considered low risk, longer periods (e.g. > 30 min) are often accepted when neuroprotective strategies.

Conclusions: TAC is a crucial tool for surgical safety, reducing intraoperative rupture, but our findings suggest a potential association with greater cerebral edema. This supports stricter intraoperative neuroprotection and monitoring, including continuous SSEP, to limit ischemia time and potentially mitigate ischemia–reperfusion-related edema, particularly in patients with pre-existing risk factors.

Figure 1 (abstract P201) Distribution of temporary aneurysm clipping by parent vessel (Left) and clip application time categories (Right). The middle cerebral artery was the most frequently clipped vessel, and in most cases temporary clipping time was ≤ 3 min

P202 Association between ventilator-associated pneumonia and escalation of intracranial hypertension therapy in TBI patients

M Lamamri, S Carville, C Jeantrelle, A Gallet, E Weiss

Assistance Publique des Hôpitaux de Paris Hôpital Beaujon, Réanimation Chirurgicale, Clichy, France

Critical Care 2026, 30 (Suppl 1): P202

Introduction: Ventilator-associated pneumonia (VAP) is the most common infection in traumatic brain injured (TBI) patients [1]. Although its impact on mortality and neurological outcome is unproven, VAP increases the duration of mechanical ventilation and ICU length of stay [2]. Through hyperthermia, hypercapnia and hypotension, VAP may induce intracranial hypertension (ICH) [3]. To date, the association between VAP and the escalation of intracranial hypertension therapy remains unexplored. The primary objective of this study was to assess whether the first episode of VAP was associated with EVD use, a first-tier treatment for ICH in TBI patients.

Methods: We conducted a retrospective study in a French ICU between April 2021 and December 2024. We included TBI patients requiring invasive mechanical ventilation and intracranial pressure monitoring upon ICU admission. Patients requiring immediate EVD placement or decompressive craniectomy upon admission were excluded. We performed a time-to-event analysis to evaluate whether the first episode of VAP was associated with the likelihood and timing of EVD insertion.

Results: We included 159 patients: most were male (119, 75%) with a median age of 42 [26–57] years, and 133 (84%) had severe TBI. VAP was observed in 82 patients (51%): among these patients, the first episode of VAP occurred within the first 7 days for 77 of them (94%). The incidence of ICH was significantly higher in the VAP group (55/82; 67%) than in the group without VAP (34/77; 44%) (OR = 2.6, 95% CI: 1.3–4.9; p = 0.006). Patients with VAP had a significantly increased risk of EVD placement compared with those without VAP (Log rank, p = 0.014) (Figure).

Conclusions: VAP was associated with higher and earlier EVD placement, underscoring that this infection can impose a significant ICH care burden in TBI patients.

References Esnault P et al. Neurocrit Care 2017;27:187–198 Robba C et al. Chest 2020;158:2292–2303 Bronchard R et al. Anesthesiology2004;100:234–239

Figure 1 (abstract P202) Kaplan–Meier survival curves representing the probability of remaining without EVD after ICU admission with 95% confidence intervals

P203 Interaction between admission hemoglobin and sex on ICU mortality in patients with traumatic brain injury: a retrospective bi-centric cohort study

M Lamamri 1 , M Werner 2 , S Sigaut 3 , J Dupont 3 , A Rodrigues 4 , A Gallet 3 , E Weiss 3 , C Jeantrelle 3

1 Assistance Publique des Hôpitaux de Paris Hôpital Beaujon, Réanimation Chirurgicale, Clichy, France, 2 Hôpital Bicêtre, Anesthésie Réanimation Chirurgicale, Le Kremlin-Bicêtre, France, 3 Assistance Publique des Hôpitaux de Paris Hôpital Beaujon, Clichy, France, 4 Assistance Publique des Hôpitaux de Paris, Hôpital Kremlin-Bicètre, Paris, France

Critical Care 2026, 30 (Suppl 1): P203

Introduction: Recent literature has been searching for a transfusion threshold in traumatic brain injury (TBI) patients [1,2]. However, general population has baseline differences in hemoglobin levels based on sex [3]. Given the male-predominant TBI epidemiology, it is essential to determine if this sex-specific physiological difference influences the prognosis.

Methods: We conducted a retrospective observational study using data from a national trauma registry across two Level 1 Trauma Centers in France from November 2010 to July 2025. The primary outcome was ICU mortality. We built multivariable logistic regression models, including a sex × hemoglobin interaction and performed causal inference analyses to estimate standardized risks, adjusting for prognostic variables.

Results: We included 5513 TBI patients. After adjustment, every 1 g/dL increase in admission hemoglobin was associated with a 22% decrease in the odds of ICU mortality (OR: 0.78, 97.5% CI [0.69–0.88], p < 0.0001). The sex × hemoglobin interaction effect was not significantly associated with ICU mortality (OR: 1.04, 97.5% CI [0.91–1.19], p = 0.433). Predicted ICU mortality risk was lower in females across all hemoglobin levels (Wald tests, all p < 0.05 from 9.0 to 13.0 g/dL). However, causal inference methods confirmed the absence of any difference in standardized ICU mortality risk at equivalent hemoglobin levels (adjusted OR: 1.01, 95% CI [0.85–1.19], p = 0.936) (Figure).

Conclusions: No interaction between admission hemoglobin and sex was found regarding ICU mortality following TBI. These findings suggest that setting sex-differentiated hemoglobin transfusion thresholds may not be required for the initial management of TBI patients.

References Turgeon AF et al. N Engl J Med 2024;391:722–735 Taccone FS, et al. JAMA 2024;332:1623–1633 Braat S, et al. Lancet Haematol 2024;11:e253-e264

Figure 1 (abstract P203) Predicted ICU mortality risk stratified by admission hemoglobin level and sex (parametric G-computation)

P204 Community-acquired versus health care-associated intracranial empyema and abscess: a 12-year single-centre cohort study

RS Hellwege 1 , M Gönel 2 , M Sebök 2 , J Sarnthein 2 , D Weller 3 , SD Brugger 3 , G Brandi 1

1 University Hospital Zurich, Institute of Intensive Care Medicine, Zurich, Switzerland, 2 University Hospital Zurich, Department of Neurosurgery, Zurich, Switzerland, 3 University Hospital Zurich, Department of Infectious Diseases and Hospital Epidemiology, Zurich, Switzerland

Critical Care 2026, 30 (Suppl 1): P204

Introduction: Intracranial empyema and abscess may occur through contiguous spread from local infections or by haematogenous dissemination from distant foci (community-acquired (CA) or complicate neurosurgery (health care–associated (HCA). Comparative ICU data between these two entities remain limited [1,2].

Methods: We retrospectively analysed adults treated for intracranial empyema or abscess (2012–2023) at a tertiary university hospital. Patients with CA or HCA were compared for clinical presentation, microbiology, ICU course, and neurological outcomes (GOSE). Neurological functional status, use of ICU resources and in-hospital mortality were analysed.

Results: Eighty-four patients were included (CA = 37, HCA = 47). CA infections presented with more severe neurological impairment (lower GCS, more focal deficits, impaired consciousness) and higher sepsis rates (43% vs 21%). ICU admission was more frequent in CA cases (81% vs 32%). CA infections were dominated by Streptococcus anginosus and anaerobes, whereas HCA infections by Staphylococcus aureus , Cutibacterium acnes , and Gram-negative rods, including AmpC producers. In-hospital mortality was 15.5%, comparable between groups. Functional outcomes were favourable and similar between groups at discharge and follow-up (median GOSE 6 vs 7 and 7 vs 7). In multivariable analysis, SAPS II was the only independent predictor of in-hospital mortality (OR 1.20 per point; 95% CI 1.05–1.37; p = 0.009) (Figure).

Conclusions: CA intracranial empyema and abscess present with more severe neurological impairment and require substantially more intensive care. Outcomes remain comparable when early diagnosis, surgical source control, and comprehensive ICU support are ensured. Severity of illness, not infection origin, is the strongest prognostic determinant.

References Brouwer MC et al. N Engl J Med 2014;371:447–56 Bodilsen J et al. Clin Microbiol Infect 2024;30:66–89

Figure 1 (abstract P204) SAPS II as the sole independent predictor of in-hospital mortality in intracranial empyema and brain abscess

P205 Brain-derived exosomal miRNA profiles in experimental sepsis-associated encephalopathy and their correlation with cerebrospinal fluid and plasma

X Qi, X Zhu

The Affiliated Hospital of Qingdao University, Qingdao, China

Critical Care 2026, 30 (Suppl 1): P205

Introduction: Sepsis-associated encephalopathy (SAE) is a diffuse brain dysfunction lacking specific diagnostic biomarkers. Exosomal miRNAs may reflect early neuropathological alterations and serve as liquid “brain biopsy” indicators. This study investigated brain-derived exosomal miRNA profiles in experimental SAE rats and examined their concordance with cerebrospinal fluid (CSF) and plasma exosomal miRNAs.

Methods: SAE was induced in rats via intraperitoneal lipopolysaccharide (LPS) injection. Brain injury, blood–brain barrier disruption, and neuronal apoptosis were confirmed histologically. Brain-derived exosomes were isolated using established ultracentrifugation and validated by TEM, NTA, and Western blotting. High-throughput sequencing was performed on exosomal miRNAs from SAE (n = 3) and control (n = 3) brain tissue. Four candidate miRNAs were selected based on differential expression and functional enrichment. Their expression in brain tissue, CSF, and plasma was verified by qRT-PCR. Correlations across compartments were analyzed using Spearman coefficients.

Results: A total of 2156 miRNAs were detected, including 101 differentially expressed miRNAs (85 upregulated, 16 downregulated) in SAE brain-derived exosomes. GO and KEGG analyses indicated enrichment in immune, inflammatory, and neuromodulatory pathways. Four miRNAs—miR-127-3p, miR-423-3p, miR-378b, and miR-106-3p—were significantly altered in SAE brain tissue ( p < 0.001) and showed identical directional changes in CSF and plasma. Strong correlations were observed between brain-derived miRNAs and corresponding CSF (rs = 0.638–0.857) and plasma miRNAs (rs = 0.690–0.795).

Conclusions: SAE markedly alters brain-derived exosomal miRNA profiles. The strong concordance between brain, CSF, and plasma miRNAs highlights their translational potential as minimally invasive biomarkers. These findings support exosomal miRNAs as promising candidates for early SAE detection and mechanistic investigation.

P206 Light assessment and systematic trends in pupillometry for ultimate prognosis in late-stage injury (Last–Pupil study)

C Avoni 1 , P Spiandorello 2 , A Addis 2 , P Mangili 2 , M Baggiani 2 , A Fornoni 2 , A Guglielmi 3 , F Graziano 4 , G Citerio 2

1 School of Medicine and Surgery, University of Milano Bicocca, Monza, Italy, 2 Neuroscience Department, NeuroIntensive Care Unit, San Gerardo Hospital, ASST Monza, Monza, Italy, 3 Alma Mater Ticinensis Foundation, Progetto Professionalità, Pavia, Italy, 4 Bicocca Bioinformatics Biostatistics and Bioimaging Center B4, School of Medicine and Surgery, University of Milano Bicocca, Milan, Italy

Critical Care 2026, 30 (Suppl 1): P206

Introduction: Bedside examination is the gold standard for diagnosing brain death (BD) [1]. Quantitative pupillometry (QP) objectively assess midbrain function through the Neurological Pupil Index (NPi) [2], but its evolution before BD is poorly described. This study analysed NPi and constriction percentage (%CH) trajectories in the 72h before BD and identified a Critical Inflection Point (CIP) defined as the last time point with the best recorded NPi and %CH before a sustained irreversible decline.

Methods: This single-center retrospective study included ICU patients ≥ 18 years meeting BD criteria at IRCCS San Gerardo Hospital (2019–2025). Pupillometry and clinical data were analyzed. Only patients with at least one NPi and %CH measurement ≠ 0 within the observation window (ICU admission or the 72h preceding BD) were included. The lowest NPi per 8h block was used.

Results: Forty-nine patients were included (median age 66 [56–71]); intracerebral hemorrhage was the most frequent admission diagnosis (28.6%). At ICU admission, the median worst NPi was 3.40 [0.00–4.00], while %CH was consistently low, with 90% of patients showing CH < 17.2%. CIP most frequently began between 72–64h before BD, with a median worst NPI of 3.30 [0.25–3.90]. In the whole cohort, the median time to CIP was 48h before BD [40–64] (Table). Both NPi and CH reached zero around 40h before BD (median 40h, [32–56]). NPi = 0 consistently preceded the disappearance of all brainstem reflexes, and a sustained NPi < 3 for 8–16h was followed by complete brainstem areflexia within 48–72h.

Conclusions: NPi and %CH seems to follow a stereotyped and temporally consistent deterioration pattern before BD. Detection of a CIP and the observation that NPi deterioration precedes brainstem areflexia suggest that QP may provide a sensitive and early marker of impending brainstem failure. These findings support the integration of pupillometry as a prognostic adjunct in BD evaluation.

References Greer DM et al. JAMA 2020;324:1078–1097 Sandroni C et al. Intensive Care Med. 2022;48:1467–70

Table (abstract P206) Temporal sequence of NPi, %CH deterioration and brainstem reflex loss in the 72h before BD

P207 Reliability of transorbital TCCD insonation of the ophthalmic artery: a valid approach for the evaluation of intracranial circulation

MC Laganà 1 , F Daniele 1 , S Benedetti 1 , E D´Agostino 1 , GM Mazza 2 , M Pagani 2 , CN Colombo 3 , G Tavazzi 4 , A Guglielmi 5

1 University of Pavia, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, Pavia, Italy, 2 Intensive Care Department 1, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy, 3 Alma Mater Ticinensis Foundation of Pavia under the Progetto Professionalità, call 2024-25, Intensive Care Department 1, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy, 4 University of Pavia, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, Pavia, Italy, 5 Alma Mater Ticinensis Foundation of Pavia under the Progetto Professionalità, call 2024-25, Pavia, Italy

Critical Care 2026, 30 (Suppl 1): P207

Introduction: The ophthalmic artery (OA), the first branch of the internal carotid artery (ICA), is important for the non-invasive assessment of anterior cerebral circulation. Transorbital OA evaluation has been used in preeclamptic women [1] and may be a marker of intracranial circulation, but data are limited [2]. We evaluated the feasibility of transorbital Transcranial Color-Coded Duplex (TCCD) of the OA (Figure), defined normative OA values and compared them with those of the middle cerebral artery (MCA) and the ICA.

Methods: Observational study of 25 volunteers undergoing TCCD of the OA, MCA and ICA with a 2-MHz phased-array probe. Peak systolic velocity (PS), end-diastolic velocity (ED), time-averaged maximum velocity (TAMAX) and pulsatility index (PI) were recorded.

Results: Participants were 13M, 12F. All values are expressed as mean ± standard deviation (SD). The OA showed excellent bilateral symmetry between the right and left: PS 38.52 ± 11.14 vs 38.42 ± 8.64 cm/s, TAMAX 17.20 ± 4.89 vs 17.13 ± 3.38 cm/s and PI 1.68 ± 0.39 vs 1.56 ± 0.48. End-diastolic velocity was slightly higher on the left (11.65 ± 6.74 cm/s) than the right (9.68 ± 3.55 cm/s), without statistical significance ( p = 0.55). PS, ED, TAMAX and PI were not different across sexes ( p > 0.05). In the MCA, females had higher TAMAX (60.87 ± 13.34 vs 52.52 ± 11.27 cm/s, p = 0.022) and lower PI 0.80 ± 0.14 vs 0.90 ± 0.13 ( p = 0.013). In the ICA, females showed higher ED (29.10 ± 5.72 vs 25.19 ± 7.62 cm/s, p = 0.044), higher TAMAX (41.07 ± 9.17 vs 32.70 ± 7.84 cm/s; p = 0.001) and lower PI (0.84 ± 0.17 vs 0.98 ± 0.25; p = 0.016).

Conclusions: TCCD is a feasible and reliable tool for evaluating OA circulation. However, further studies are needed to expand the population and validate normal TCCD values for age. A better understanding of OA hemodynamics in pathological settings is needed to support its use in the non-invasive assessment of intracranial circulation.

References Vaz de Melo PFM et al. BMC Pregnancy Childbirth 2023;23:343 Robinson L et al. Brain Res 2019;1710:43–60

Figure 1 (abstract P207) Transcranial color-coded duplex (TCCD) image of the ophthalmic artery: the color image shows flow directed toward the probe (color-coded in red), and the pulsed-wave Doppler trace displays a high-resistance spectral pattern typical of the ophthalmic artery, with distinct systolic peaks and low diastolic flow

P208 Predictors of mechanical ventilation and unfavourable outcome in patients with severe tick-borne encephalitis in Slovenia

N Grasselli 1 , M Mavric 1 , D Stupica 1 , M Veluscek 1 , S Makarovic 2

1 University Medical Center Ljubljana, Ljubljana, Slovenia, 2 Faculty Of Medicine Ljubljana, Ljubljana, Slovenia

Critical Care 2026, 30 (Suppl 1): P208

Introduction: Tick-borne encephalitis (TBE) is an endemic zoonotic viral central nervous system infection in Slovenia. In 2006, Jereb et al. reported a 9% mortality among intensive care unit (ICU) patients, with no breakthrough infections [1]. The aim of this retrospective study was to evaluate epidemiological, clinical, and laboratory characteristics of patients with severe TBE requiring ICU treatment in Slovenia from 2014–2024. Secondary objective was to analyse and predict mechanical ventilation (MV) characteristics and predictors of death.

Methods: All adult patients (> 18 years) with TBE, hospitalised in the Infectious Diseases ICU of the University Medical Centre Ljubljana, Slovenia, between 1.1.2014–31.12.2024 were included retrospectively. Data was extracted from medical documentation. Severe TBE was defined as positive serum TBE serology and need for ICU treatment. P values < 0.05 were considered statistically significant.

Results: Among 74 included patients (mean age 64.9 ± 15.9 years; 60.8% males) the mean Charlson comorbidity index was 3.1 ± 2.2). 6 patients (8.1%) were previously fully vaccinated against TBE. 40 patients (54%) needed MV, and 4 patients (5%) died. Mean ICU length of stay was 25.1 ± 55.2 days and mean MV time 403.6 ± 1034.6 h. Important statistically significant predictors of MV or prolonged MV (> 21 days) are presented in the Table. Hazard ratio for mortality (95% CI: 1.048–38.640; p = 0.044) in patients with elevated cerebrospinal (CSF) protein concentration was 6-times higher.

Conclusions: Results of our study show that patients with TBE, who require ICU treatment are older with multiple comorbidities, and the mean length of MV often exceeds 21 days. Compared to the cohort from 2001–2005 [1], our findings show lower mortality, but detection of breakthrough infections. For the first time our study identifies significant predictors of MV (advanced age, MRI changes, peripheral paresis) and death (elevated CSF protein concentration).

Reference Jereb M et al. Wien Klin Wochenschr 2006;118:765–8

Table (abstract P208) Statistically significant predictors of mechanical ventilation or prolonged mechanical ventilation (> 21 days) in patients with severe tick-borne encephalitis

P209 Impact of intracranial pressure on low cerebral perfusion pressure tolerability and outcome in traumatic brain injury

F Tokmak 1 , F Güiza 1 , B Depreitere 2 , G Meyfroidt 1 , On Behalf of the BrainIT Group

1 KU Leuven, Laboratory of Intensive Care Medicine, Leuven, Belgium, 2 KU Leuven, Research Group Experimental Neurosurgery and Neuroanatomy, Leuven, Belgium

Critical Care 2026, 30 (Suppl 1): P209

Introduction: Increasing intracranial pressure (ICP) reduces the effective cerebral perfusion pressure (CPP) [1] and is often accompanied by reduced brain compliance, which may affect how patients respond to periods of low CPP. However, the effect of ICP on the tolerability for low CPP has not been systemically studied, and in this study, we aimed to visualize the low CPP burden in relation to patient outcomes across different ICP values.

Methods: 161 adult patients with minute-by-minute ICP, CPP data along with Glasgow Outcome Score (GOS) at 6 months from BRAIN-IT dataset (collected between March 2003 and July 2005 across 22 neuro-ICUs in 11 European countries) [2] were included in the analysis. Using the algorithm described by Güiza et al. [3], color-coded insult burden plots for CPP were visualized by correlating frequency of low CPP episodes —defined by both intensity and duration— with neurological outcomes. Five visualizations were generated for CPP episodes occurring while mean ICP exceeded > 12, 14, 16, 18, or 20 mmHg, and the transition curves derived from these were displayed together for comparison.

Results: Our visualizations revealed that as ICP increases, the transition curves separating harmful low CPP doses from non-harmful ones shift to the right, representing a reduced tolerability for low CPP and an increase in CPP dose threshold associated with unfavorable outcomes (see Figure).

Conclusions: Beyond decreasing CPP and compromising brain compliance, increasing ICP appears to further affect clinical outcome by reducing tolerability for low CPP. Further research may focus on the mathematical formulation of the relationship between ICP and the shift in the CPP curve to provide clinically actionable information.

References Thees C et al. Anesthesiology 2002;96:595–599 Piper I et al. Acta Neurochir (Wien) 2003;145:615–629 Güiza F et al. Intensive Care Med 2015;41:1067–1076

Figure 1 (abstract P209) A) Insult-burden curve showing how GOS relates to the average number of low CPP insults. Each intensity-duration pair defines an insult type, where CPP is below that intensity for the corresponding duration, and is shown as a point colored by its association with outcome (blue = positive, red = negative). The black contour marks the transition curve. (B) Transition curves for CPP episodes occurring during ICP > 12, 14, 16, 18, and 20 mmHg

P210 Risk factors of external ventricular drain weaning failure in patients with moderate to severe traumatic brain injury

P Joly 1 , S Aubert 1 , A Parrin 2 , M Faillot 3 , E Weiss 1 , M Lamamri 1

1 Assistance Publique des Hôpitaux de Paris Hôpital Beaujon, Critical Care, Clichy, France, 2 Assistance Publique des Hôpitaux de Paris Hôpital Beaujon, Anesthesiology, Clichy, France, 3 Assistance Publique des Hôpitaux de Paris Hôpital Beaujon, Neurosurgery, Clichy, France

Critical Care 2026, 30 (Suppl 1): P210

Introduction: External ventricular drain (EVD) is commonly used in Traumatic brain injured (TBI) patients’ management to control of intracranial pressure through cerebrospinal fluid (CSF) diversion [1]. No study focused on the risk factors of EVD weaning failure in this specific population. The aim of the study was to evaluate the risk factors associated with EVD weaning failure in TBI patients.

Methods: We conducted a retrospective monocentric study in a French Level 1 trauma center between January 2011 and January 2024. We included all patients with TBI who required an EVD. Failure of EVD weaning was defined by either the necessity of unclamping the EVD during the clamping trial, or the reinsertion of a new EVD, or by the necessity for permanent CSF diversion. A multivariate logistic regression model was performed to identify independent risk factors.

Results: During the study period, 128 TBI patients required an EVD. Patients were mostly men (85%), with a median age of 33 years. Failure of EVD weaning was observed in 15 patients (19%). Those patients were older than patients with success of weaning (median age of 35 versus 31, p = 0.015) (Table). The only risk factor associated with EVD weaning was EVD infection (ventriculitis/ meningitis) (OR 7.39, 95% CI 1.45–37.7 p = 0.03). Persistence of intraventricular hemorrhage on the follow-up brain CT scan before EVD weaning was also associated with EVD weaning failure, with an odds ratio of 5.43 (95% CI: 1.48–20.0, p = 0.012).

Conclusions: The risk factors associated with EVD weaning failure were the infection of the EVD and the persistence of intraventricular hemorrhage on the follow-up brain CT scan before EVD weaning in TBI patients.

Reference Stocchetti N et al. N Engl J Med 2014;370:2121–2130

Table (abstract P210) Comparison of variables according to EVD weaning success or failure

P211 Prognosis of severely traumatized patients with associated traumatic brain injury: the impact of extra-cranial lesions

K Cheour, W Demni, Y Walha, D Hamdi, K Ouerhani, F Lachtar, N Nouira

Monji Slim Hospital, Emergency Department, Tunis, Tunisia

Critical Care 2026, 30 (Suppl 1): P211

Introduction: Traumatic brain injury (TBI) represents a major public health concern. When it occurs in the context of polytrauma, extra-cranial injuries (ECIs) may worsen the prognosis. The aim of the study was to evaluate the impact of ECIs on in-hospital mortality and functional outcome in severely injured patients with TBI.

Methods: This was a prospective observational study conducted in the emergency department of Mongi Slim Hospital in Tunisia over a two-year period. We included patients aged 15 years and older, who sustained severe trauma with a TBI confirmed by brain CT findings, with or without ECIs. Outcomes were in-hospital mortality and the presence of motor disability at hospital discharge (assessed using the Glasgow Outcome Scale(GOS). To evaluate the impact of ECIs on both vital and neurological functional outcomes, patients were divided into two groups “isolated TBI” and “TBI with ECIs.”

Results: We included 202 patients. The mean age was 41 ± 18 years. The male-to-female ratio was 4.05. All patients presented with brain CT abnormalities, primarily subarachnoid hemorrhage (40.6%), cerebral edema (39.6%) and epidural or subdural hematoma (23.3%). ECIs were present in 63.9% of cases. In-hospital mortality was 26.7%. Unfavorable outcome (GOS ≤ 3) was noted in 30.7% of patients. ECIs were not significantly associated with in-hospital mortality or unfavorable neurological outcomes. Independent predictors of unfavorable outcome in multivariate analysis were: Oxygen saturation < 90% ( p = 0.006), Requirement for mechanical ventilation ( p < 0.001), Serum creatinine > 110 µmol/L ( p = 0.01), Reverse Shock Index < 1 ( p = 0.001) and midline shift on brain CT ( p = 0.002). The median survival time was shorter in the group with TBI and associated ECIs (28 vs 40 days) but the difference was not statistically significant ( p = 0.7).

Conclusions: ECTs are not predictive factors of in-hospital mortality or functional disability in severely injured patients with traumatic brain injury.

P212 Early vs late nutrition in traumatic brain injury: a secondary analysis of the Center-TBI study

G Mazza 1 , A Guglielmi 2 , A Fornoni 3 , F Graziano 4 , FS Taccone 5 , G Citerio 6

1 Fondazione IRCCS Policlinico San Matteo, Intensive Care Department 1, Pavia, Italy, 2 University of Pavia, PhD in Experimental Medicine, Pavia, Italy, 3 Neurointensive Care Unit, IRCCS San Gerardo dei Tintori, Monza, Italy, 4 Neurointensive Care Unit, Biostatistics and Clinical Epidemiology, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy, 5 Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, 1070, Brussels, Belgium, 6 School of Medicine and Surgery, University of MilanoBicocca, Milan, Italy

Critical Care 2026, 30 (Suppl 1): P212

Introduction: Artificial nutrition in TBI is crucial due to its potential influence on clinical outcomes. Current guidelines recommend early nutrition (EN) as soon as possible, ideally within 48h after injury. Clinical practice remains highly heterogeneous, and a large-scale description is currently lacking. The primary objective of this study is to describe the practice of artificial nutrition in TBI patients.

Methods: Secondary analysis of the CENTER-TBI study, enrolling patients with GCS < 13 admitted to the ICU. Patient’s characteristics, daily nutritional therapy, fluid balance and therapy intensity level (TIL) in the first week were collected. EN was defined within 48h after injury; late nutrition (LN) was defined after 48h from injury. Outcome data were collected.

Results: During the first week in ICU, 746 (75.8%) patients received EN. Among patients initiating LN, 88 (8.9%) received nutrition between 3 and 7 days while 150 (15.2%) didn’t receive any nutritional. No significant difference was found between patients receiving EN or LN regarding previous medical history and severity of trauma (GCS, pupillary reactivity, ISS, and Marshall CT classification). Nevertheless, EN group had more frequent neurological deterioration, received more frequently ICP monitoring, higher TIL and had a positive fluid balance. Patients in the EN group had higher incidence of ventilator associated pneumonia (27% VS 10.9%, p < 0.001), longer duration of ventilation [10 (5–18) vs 7 (2–12) days, p < 0.001], longer time of ICU stay [336 (192–528) vs 216 (96–408) days, p < 0.001) and longer time to obey commands [ 7 (3 -14) vs 3.5 (1 – 10) days, p < 0.001]. GOSE at 6m was lower in patients in the EN group (Figure).

Conclusions: Despite similar baseline characteristics between the two groups, EN-group presented higher severity during the first week in ICU, having a worse outcome.

Reference Singer P et al. Clin Nutr 2023;42:1671–89

Figure 1 (abstract P212) GOS-E at 6 months by nutrition group

P213 High-risk spine surgery in older adults: predictors of intraoperative bleeding and implications for hemodynamic optimization

MC Niño de Mejia 1 , D Cohen 1 , MF Parada 1 , A Romero 2

1 Hospital Universitario Fundacion Santa Fe de Bogota, Anestesiologia, Bogotá, Colombia, 2 Hospital Universitario Fundacion Santa Fe de Bogota, Bogotá, Colombia

Critical Care 2026, 30 (Suppl 1): P213

Introduction: Spine surgery increasingly involves older, multimorbid patients exposed to larger, instrumented procedures. In this context, strict hemodynamic management is crucial, and intraoperative bleeding is a key driver of instability and postoperative complications. We aimed to identify clinical and intraoperative factors associated with significant bleeding.

Methods: Retrospective analysis of 724 consecutive spine surgeries of patients over 60 years. Bleeding was categorized as ≤ 500 or > 500 mL. Bivariate associations were explored between bleeding and surgical position, frailty (MFI-5), cardiovascular comorbidity and other perioperative variables. Chi-square tests were used to estimate p values.

Results: High-volume bleeding (> 500 mL) occurred in 100 patients (13.8%). Prone positioning, the predominant approach for extensive cases, concentrated 92% of all high-bleeding events and showed a strong association with bleeding (supine 4.2% vs prone 16.5%, p = 0.0002) (Table). Frail patients (MFI-5 ≥ 2) showed a slightly higher proportion of bleeding (14.7% vs 13.6% in non-frail, p = 0.85), while cardiovascular comorbidity displayed similar rates (12.7% vs 13.9%, p = 0.93). Overall immediate postoperative complications were infrequent (2.6%) without direct correlation with bleeding.

Conclusions: In a large cohort of older adults undergoing spine surgery, intraoperative bleeding was strongly linked to prone positioning, reflecting the complexity of these operations. Frailty and cardiovascular comorbidity did not reach statistical significance but remained clinically relevant markers of hemodynamic vulnerability. Integrating frailty, comorbidity profiles and procedural complexity into preoperative planning, together with meticulous real-time hemodynamic management, may be essential to reducing bleeding-related instability and improving outcomes in contemporary spine surgery.

Table (abstract P213) Key predictors of intraoperative bleeding (> 500 mL) in spine surgery

P214 Time burden analysis of perfusion metrics following traumatic spinal cord injury

F Tokmak 1 , L Chibuzor Ilochonwu 2 , F Güiza 1 , B Depreitere 3 , MC Papadopoulos 2 , S Saadoun 2 , G Meyfroidt 1

1 KU Leuven, Laboratory of Intensive Care Medicine, Leuven, Belgium, 2 City St. George´s, University of London, Academic Neurosurgery Unit, London, UK, 3 KU Leuven, Research Group Experimental Neurosurgery and Neuroanatomy, Leuven, Belgium

Critical Care 2026, 30 (Suppl 1): P214

Introduction: High intraspinal pressure (ISP) may hamper the perfusion by reducing spinal cord perfusion pressure (SCPP) [1]; yet, there are no guidelines on managing these metrics for optimal perfusion after traumatic spinal cord injury (TSCI). In this study, we visualized the insult burden curves for ISP and SCPP to quantify secondary injuries in TSCI patients.

Methods: 91 patients with TSCI were recruited for data collection. Minute-by-minute ISP, mean arterial pressure (MAP), and SCPP data were collected and prospectively analyzed. The frequency of ISP and SCPP episodes (defined by intensity and duration) was correlated with the American Spinal Injury Association Impairment Scale (AIS) grade at admission and follow-up, as well as with AIS grade improvement, defined as the difference between follow-up and admission AIS grades. Using the algorithm described by Güiza et al. [2], results were visualized as color-coded burden plots, with a color map ranging from blue to red, where red indicates the strong negative association with the variable of interest.

Results: High ISP doses were associated with worse follow-up AIS grades and were even more strongly associated with worse admission AIS, but showed no clear relationship with AIS improvement (Figure). This suggests that the link between follow-up status and ISP dose may be confounded by the association between admission AIS and ISP. On the other hand, low SCPP doses were associated with both worse admission and follow-up status, as well as with less AIS grade improvement (Figure).

Conclusions: Time burden analysis of ISP and SCPP revealed that SCPP showed a clearer association with patient prognosis and may represent a better therapeutic target than ISP. In our analysis, ISP appeared to be more related to injury severity and patients’ admission status.

References Werndle MC et al. Crit Care Med 2014;42:646–655 Güiza F et al. Intensive Care Med 2015;41:1067–1076

Figure 1 (abstract P214) Insult burden curves for ISP (A–C) and SCPP (D–F) episodes, illustrating how average insult counts relate to AIS grade at admission, follow-up, and AIS improvement (left to right). Each intensity–duration pair defines an insult, where the signal stays above (ISP) or below (SCPP) the specified threshold for at least corresponding duration, and is shown as a point. Points are color-coded by the strength and direction of their association with the outcome, from blue (positive) to red (negative)

P215 Long-term outcomes after neuroICU care: results from the Lombardia neurointensive care network (LINK) cohort

M Baggiani 1 , S Piva 2 , M Amigoni 1 , A Guglielmi 3 , P Mangili 1 , G Citerio 4

1 Neurointensive Care Unit, IRCCS San Gerardo dei Tintori, Monza, Italy, 2 Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, Università di Brescia, and Department of Emergency, Spedali Civili University Hospital, Brescia, Italy, 3 University of Pavia, PhD in Experimental Medicine, Pavia, Italy, 4 School of Medicine and Surgery, University of MilanoBicocca, Milan, Italy

Critical Care 2026, 30 (Suppl 1): P215

Introduction: Post-Intensive Care Syndrome (PICS) is common after Neuro-Intensive Care (NIC). Its manifestations often overlap with the acute neurological injury, making ICU-acquired sequelae hard to distinguish. To address this challenge, the LINK network [1] launched a prospective, multicentre follow-up programme at 6, 12, and 24 months across 18 hospitals, aiming to detect and characterise post-NIC sequelae systematically.

Methods: From January 2025, we prospectively enrolled consecutive adults admitted to NICs (372 h). Standardised assessments were performed during the ICU stay and at 6 months, evaluating physical, cognitive, psychological, and functional domains using validated tools administered in person or by telephone.

Results: A total of 666 patients were enrolled (mean age 58 ± 17 years; 62% male) (Table). Primary diagnoses were traumatic brain injury (25%), subarachnoid haemorrhage (17%), and intracerebral haemorrhage (18%). Median [IQR] admission GCS was 8 [5–11], and mean SAPS II was 39 ± 15. Mechanical ventilation was required in 88% for 8 ± 7 days, and 78% received sedation for 5 ± 4 days. Mean ICU length of stay was 23 ± 4 days, with 14% of mortality. By hospital discharge, 559 (84%) had regained consciousness. At 6 months, overall mortality was 16%. Severe disability remained common: 52 (44%) had GOSE ≤ 3, including 8 (7%) who were in a vegetative state. Ninety-seven/116 (88%) did not regain their previous work.

Conclusions: NIC survivors showed PICS with persistent frailty, functional dependence, and limited return to work at 6 months. The LINK network enabled harmonised multicentre long-term follow-up, revealing unmet needs and ongoing PICS-related impairments. This structured regional model demonstrates feasibility and clinical value, supporting coordinated long-term care and laying the groundwork for targeted rehabilitation and future studies.

Reference Guglielmi A et al. J Anesth Analg Crit Care 2025;5:87

Table (abstract P215) Results *Numbers in the denominator in each cell represent the evaluated patients HGD = Handgrip Dynamometry. 6MWT = 6-min walk test. HADS = Hospital Anxiety and Depression Scale. PTDS = Post-Traumatic Stress Disorders. PCL-5 = PTSD Checklist for DSM-5 (PCL-5). MoCA = Montreal Cognitive Assessment.

P216 PIEZO2 genetic variations are associated with increased severity and mortality of COVID-19

K Li 1 , Y Ge 1 , S Geng 1 , H Hu 2 , X Yue 2 , Y Zhu 2 , Z Li 2 , Y Zhang 2 , L Liu 1 , W Huang 1

1 Southeast University, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Nanjing, China, 2 Southeast University, School of Medicine, Nanjing, China

Critical Care 2026, 30 (Suppl 1): P216

Introduction: Given that heightened respiratory drive is a key feature of COVID-19, we aim to investigate whether specific genetic variants in PIEZO2—a mechanosensitive ion channel critical for tidal volume regulation—can serve as such biomarkers [1,2].

Methods: This retrospective study of COVID-19 inpatients (December 2022 to February 2023) investigated the associations of PIEZO2 single-nucleotide polymorphisms (SNPs) with 28-day mortality (primary outcome, analyzed by Cox regression) and disease severity (secondary outcome, defined by the highest level of respiratory support and analyzed by logistic regression) [3,4]. Linkage disequilibrium (LD) analysis (r 2 metric) characterized the genetic relationships among PIEZO2 SNPs.

Results: 313 COVID-19 patients were successfully genotyped for four PIEZO2 SNPs and enrolled. LD analysis of four PIEZO2 SNPs revealed two SNP pairs in complete LD: rs73943314/rs9954308 and rs875956/rs2277858 (r 2 = 1). When stratified by 28-day survival, the non-survivor group had significantly higher minor allele frequencies of the four PIEZO2 SNPs than the survivor group ( p < 0.001). After adjusting for confounding factors, rs875956 (CT + TT vs. CC) and rs2277858 (TC + CC vs. TT) were associated with an increased risk of 28-day mortality (HR = 2.12, 95%CI 1.03–4.37, p = 0.040). In a multivariable analyses, rs73943314 (TC + CC vs. TT) and rs9954308 (TC + CC vs. TT) were independent risk factors for severe COVID-19 (OR 1.94, 95%CI 1.07–3.55, p = 0.030), as were rs875956 (CT + TT vs. CC) and rs2277858 (TC + CC vs. TT) (OR 2.07, 95%CI 1.26–3.40, p = 0.004).

Conclusions: Minor alleles of PIEZO2 SNPs are associated with increased severity and increased 28-day mortality in COVID-19 patients.

References Gattinoni L et al. Am J Respir Crit Care Med 2020;202:1079–80 Nonomura K et al. Nature 2017;541:176–81 JIANG B et al. Eur Rev Med Pharmacol Sci 2020;24:10,239–46 Meyer NJ et al. Lancet 2021;398:622–37

P219 Lactylation of S100A9 protein: a new insight into sepsis-associated lung injury

X Zheng 1 , F Gong 2 , W Xu 2 , Y Han 2 , D Xu 2 , H Liu 2 , R Li 2 , Y Chen 2 , E Chen 2

1 Ruijin Hospital, Shanghai Jiao Tong University School Of Medicine, Shanghai, China, 2 Ruijin Hospital, Shanghai Jiao Tong University School Of Medicine, Department Of Emergency, Shanghai, China

Critical Care 2026, 30 (Suppl 1): P219

Introduction: Sepsis is a life-threatening systemic inflammatory condition often complicated by acute lung injury (ALI), with limited therapeutic options. The pathophysiology of sepsis-induced organ dysfunction remains poorly understood, highlighting the need for novel insights into disease mechanisms. This study investigates the role of (S100A9 in sepsis-associated ALI, focusing on its post-translational modifications and their implications in inflammation and tissue damage.

Methods: Through lactylation proteomics and immunoprecipitation, we identified that S100A9 undergoes lactylation at K4 and K94. Using BMDM cells and confocal microscopy, we demonstrated S100A9 nuclear translocation and its regulation by lactylation. Subsequent mass spectrometry, CUT&Tag, and RNA sequencing revealed that S100A9 interacts with CEBPB to regulate IL-1β transcriptional activation.

Results: We identified that S100A9 undergoes lactylation at lysine residues K4 and K94. LPS stimulation enhances S100A9’s colocalization with the nucleus and its presence in nuclear fractions. Furthermore, lactylation of S100A9 enhances its nuclear translocation, and through interaction with Cebpb, it regulates the transcriptional activation of IL-1β, thereby mediating inflammatory responses that contribute to sepsis-induced lung injury.

Conclusions: In this study, we revealed the specific mechanism of sepsis-induced lung injury through S100A9 lactylation modification and its interaction with transcription factor Cebpb to regulate pro-inflammatory IL-1β gene transcription. Further research is needed to validate these findings and explore their therapeutic implications, particularly in the context of clinical nutrition and metabolic interventions to improve patient outcomes in sepsis-associated ALI.

P221 The emerging role of a novel circMYO9B-encoded peptide, MYO9B-446AA, in sepsis pathogenesis

Z Xie 1 , M Xue 2 , H Wang 2 , X Wu 2 , Y Huang 2 , W Huang 2

1 Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China, 2 Jiangsu Provincial Key Laboratory of Critical Care Medicine, Nanjing, China

Critical Care 2026, 30 (Suppl 1): P221

Introduction: The mechanisms underlying sepsis remain unclear. We investigated a protein-coding circRNA, circMYO9B, and its encoded peptide as potential regulators and biomarkers in sepsis.

Methods: Differentially expressed circRNAs in human peripheral blood were identified by microarray and RNA-seq. Coding potential was assessed using CPC2 and ORFfinder. The circular structure was validated by RNase R digestion and Sanger sequencing. Translational capacity was examined by expressing FLAG/HA-tagged constructs in HEK293T cells followed by Western blotting. circMYO9B expression in clinical samples was quantified by RT-qPCR and correlated with outcomes. Immune-cell subsets from healthy donors were sorted for expression profiling. Subcellular localization of the encoded peptide was analyzed by cytoplasmic-nuclear fractionation. Interacting proteins were identified by IP/MS with subsequent functional enrichment.

Results: Integrating two datasets (sepsis vs. controls and septic shock vs. sepsis) with circBase yielded four candidate circRNAs (|FC|> 1.2, p < 0.05). One was removed for inconsistent ORF predictions. Among the remaining three (CPC2 > 0.7 and ORF > 25 aa), circMYO9B—with the highest coding score—was selected. Its back-splice junction and RNase R resistance were confirmed. Overexpression of tagged circMYO9B produced a peptide of the expected size, designated MYO9B-446aa. circMYO9B levels were elevated in sepsis and associated with higher mortality. Fractionation localized MYO9B-446aa to the cytoplasm. Expression profiling showed circMYO9B is enriched in CD8⁺ T cells. IP/MS identified MYO9B-446aa-binding proteins enriched in proteasome function, complement activation, immunoglobulin responses, and necroptosis—pathways central to CD8⁺ T-cell antigen processing and cytotoxicity.

Conclusions: circMYO9B encodes a novel peptide, MYO9B-446aa, is upregulated in sepsis, and is linked to CD8⁺ T-cell–related immune pathways, suggesting a potential role in sepsis-associated immune dysfunction.

P222 ADAR1 governs sepsis pathogenesis by modulating monocyte senescence

W Huang 1 , WT Li 2 , K Fang 3

1 Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Department of Critical Care Medicine, Nanjing, China, 2 Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China, 3 Key Laboratory of Developmental Genes and Human Disease, School of Life Science and Technology, Southeast University, Nanjing, Jiangsu, China

Critical Care 2026, 30 (Suppl 1): P222

Introduction: Immunosenescence refers to the abnormal activation or dysfunction of the immune system as people age, characterized by excessive expression of proinflammatory cytokines in aged immune cells [1]. However, its specific role and regulatory mechanisms in sepsis remain poorly understood. This study aims to define the clinical impact of cellular senescence in sepsis and to identify the key regulator orchestrating this process.

Methods: We first calculated senescence scores in a large sepsis cohort using an established transcriptomic signature to assess prognostic value, then employed single-cell RNA-seq of patient and healthy donor PBMCs to identify the key senescent cell population, and finally validated the function of the top candidate ADAR1 by mouse model subjected to CLP-induced sepsis.

Results: A high senescence score was associated with an increased risk of 28-day mortality in sepsis patients. scRNA-seq analysis revealed a significant elevation of senescence signatures specifically in monocytes from septic patients compared to healthy controls. Further bioinformatic dissection nominated ADAR1, an RNA-editing enzyme, as the top negative correlate of monocyte senescence. We generated a monocyte-specific Adar1 knockout (Adar1-mKO) mouse model, which exhibited a disrupted monocyte homeostasis with markedly enhanced senescence—mirroring the human phenotype. When challenged with CLP, these Adar1-cko mice suffered significantly higher mortality compared to their wild-type littermates.

Conclusions: Our study identifies ADAR1 as a novel guardian of monocyte homeostasis, revealing the ADAR1-senescence axis as a promising immunomodulatory target.

Reference Fu Y et al. Signal Transduct Target Ther 2025;10:250

P223 A procoagulant immature neutrophil state fuels early immunothrombosis in sepsis

WH Hu, SL Liu, QP Peng, WH Huang, XW Wu, YH Huang

Zhongda Hospital, School of Medicine, Southeast University, Department of Critical Care Medicine Jiangsu Provincial Key Laboratory of Critical Care Medicine, Nanjing, China

Critical Care 2026, 30 (Suppl 1): P223

Introduction: Sepsis-induced coagulopathy (SIC) reflects dysregulated immunothrombosis that propagates microvascular thrombosis and organ failure. Neutrophils are implicated, yet the developmental stage and effector programs responsible remain undefined. We posit that expanded immature neutrophils acquire a distinct procoagulant, degranulation-linked phenotype that fuels early microthrombus formation.

Methods: We mapped early pulmonary thrombus formation after cecal ligation and puncture (CLP) using intravital two-photon microscopy and digital pathology, combined with in vivo neutrophil depletion to test causality. Neutrophil states were resolved by single-cell RNA sequencing integrated with high-throughput flow cytometry and examined in parallel in murine models and a sepsis patient cohort.

Results: Intravital imaging at 4 h post-CLP revealed rapid neutrophil recruitment to the pulmonary microvasculature, promoting neutrophil–platelet aggregates and seeding microthrombi. Digital pathology showed a time-dependent increase in microthrombus burden, predominantly in small intrapulmonary vessels, whereas neutrophil depletion markedly reduced pulmonary microthrombi. Single-cell analysis resolved heterogeneity of neutrophil subtypes and revealed a marked expansion of immature populations with a distinct procoagulant, degranulation-associated program; flow cytometry confirmed a progressive increase in Ly6G⁺CD101⁻ immature neutrophils (blood, sham 17.2% vs 4 h post-CLP 80.2%) with a reciprocal loss of mature cells, closely paralleling microthrombosis kinetics. In a sepsis patient cohort, higher proportions of CD10⁻ immature neutrophils were associated with increased SIC scores (r = 0.52, p < 0.0001).

Conclusions: Expanded immature neutrophils represent a dominant effector state underpinning early sepsis immunothrombosis, positioning degranulation as a tractable therapeutic axis. The parallel association with SIC severity in patients provides critical clinical validation.

P225 Expansion and transdifferentiation of CD177⁺ neutrophils promote lung injury in sepsis-induced ARDS

Y Tang, Z Yu, J Zhang, L Jia, J Xie, Y Yang

Zhongda Hospital, Southeast University, Jiangsu Provincial Key Laboratory of Critical Care Medicine, Nanjing, China

Critical Care 2026, 30 (Suppl 1): P225

Introduction: Sepsis is the second leading cause of death worldwide, with approximately 50 million new cases and 11 million deaths each year [1], and the lung is the most vulnerable organ [2]. This study aims to elucidate the mechanisms underlying the pathogenesis of sepsis-induced ARDS.

Methods: We collected paired bronchoalveolar lavage fluid (BALF) and peripheral blood mononuclear cells (PBMCs) from sepsis patients with or without ARDS, and one postoperative transitional patient, and performed single-cell transcriptomics with plasma proteomics (Figure, panels A-B). Flow cytometry was used to quantify cell subsets, and H&E staining to assess lung injury.

Results: We found that neutrophils were markedly increased in the PBMC of sepsis patients with ARDS, consistent with recent reports [3,4]. Milo analysis identified CD177⁺ neutrophils as the most markedly expanded subset in ARDS patients (Figure, panels C, D). Plasma proteomics demonstrated elevated soluble CD177 levels in patients with ARDS (Figure, panel E). Flow cytometry confirmed an increase of CD177⁺ neutrophils in ARDS patients (Figure, panels F, G). In the CLP mouse model, CD177-neutralizing antibody treatment attenuated sepsis-induced lung injury (Figure, panel H). Mechanistically, CD177⁺ neutrophils transdifferentiate into long-lived reverse transendothelial migration neutrophils that we previously reported when they migrate from the peripheral blood into the lungs (Figure) [5], sustaining proinflammatory cytokine release and aggravating lung injury.

Conclusions: During sepsis, CD177 + neutrophils markedly expand within the PBMC fraction, migrate into the lungs, and transdifferentiate into reverse transendothelial migration neutrophils, ultimately aggravating lung injury.

References Xie J et al. Crit Care Med 2020;48:e209-e218 Englert JA et al. JCI Insight 2019;4:e124061 Qiu X et al. J Leukoc Biol 2021;110:1253–68 de Toledo MA et al. J Leukoc Biol 2025;117:qiaf027 Zi SF et al. Adv Sci 2024;11:e2400647

Figure 1 (abstract P225) Expansion and transdifferentiation of CD177⁺ neutrophils promote lung injury in sepsis-induced ARDS

P226 Cell adhesion molecules contribute to the outcomes of sepsis in diabetes mellitus

Y Qiao 1 , H Chen 2 , X Zhou 2 , H Lu 2 , K Fang 2 , W Huang 2

1 Southeast University, School of Life Science and Technology, Nanjing, China, 2 Southeast University, Nanjing, China

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Introduction: The growing global burden of diabetes mellitus (DM) has been paralleled by a rise in sepsis cases among diabetic patients. This study aimed to explore the effect and mechanisms through which DM modulate the outcome of sepsis.

Methods: C57 mice were used for DM modeling by intraperitoneal injection of streptozotocin (STZ, 60 mg/kg) for 5 days. LPS (2.5/5/15/20 mg/kg) and cecal ligation and puncture (CLP) were used to induce sepsis. Raw gene expression data GSE65682 from 802 subjects (42 healthy controls, 89 sepsis + DM, 301 sepsis-only) were retrieved from the Gene Expression Omnibus (GEO) database. Differentially expressed genes (DEGs) were screened with fold change (FC) ≥ 1.35, followed by pathway enrichment analysis ( p < 0.05). 390 sepsis patients were stratified into high- and low-expression groups based on key gene levels to analyze 28-day survival.

Results: Across all LPS doses (2.5–20 mg/kg), diabetic mice exhibited significantly higher mortality than non-diabetic controls. This disparity was most pronounced at low-to-moderate doses (2.5–5 mg/kg), where mortality was dose-dependent in diabetic mice but absent in controls. Consistently, the polymicrobial CLP model demonstrated markedly reduced survival in diabetic mice (20% vs 60% in controls). Bioinformatics analysis of the GEO dataset identified 622 DEGs in sepsis + DM group and 680 DEGs in sepsis-only group, each relative to healthy controls. Both groups showed enrichment in inflammation/immune pathways, while sepsis + DM group was uniquely enriched in the cell adhesion molecule pathway ( p = 0.004). Key adhesion gene CD2 were upregulated and expression translated to a significant survival benefit, with high levels predicting improved 28-day survival in both the overall ( p = 0.0066) and sepsis + DM cohorts ( p = 0.0134).

Conclusions: DM exacerbates sepsis severity, and the cell adhesion molecule pathway, particularly CD2, may play a critical role in this process. This study provides potential target for clinical interventions in diabetic patients with sepsis.

P228 Potential of cGAS-STING pathway as a treatment target in acute lung injury

S Zubyte 1 , M Fish 2 , J Rynne 1 , A Abdalla 1 , AG Rossi 1 , K Mackenzie 1 , M Shankar-Hari 1

1 The University of Edinburgh, Institute for Regeneration and Repair, Edinburgh, UK, 2 Massachusetts General Hospital and Harvard Medical School, Boston, USA

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Introduction: Inflammatory acute lung injury (ALI) in acute respiratory distress syndrome (ARDS) is characterised by diffuse alveolar damage (DAD). The cyclic GMP–AMP synthase (cGAS)–stimulator of interferon genes (STING) pathway is activated by double-stranded DNA and leads to acute inflammation. We hypothesised that DAD in ARDS could be associated with dysregulated activation of the cGAS-STING pathway.

Methods: We assessed evidence for cGAS-STING pathway activation in ARDS at transcriptome, cytokine, histone and cell phenotype levels using (a) blood samples from patients with acute infection-induced ARDS (n = 69) compared to controls (n = 30); (b) lipopolysaccharide-induced ex vivo lung perfusion (LPS-EVLP) injury model (n = 8) and (c) epithelial cell-enriched human lung organoids stimulated with STING agonist diABZI (n = 4).

Results: Compared with controls, ARDS patients had significantly higher expression of CGAS and TBK1 genes, higher interleukins (IL-6, IL-8) and higher citrullinated histone levels found in DNA-enriched NETs (Mann Whitney U test; p < 0.0001). The LPS-EVLP injury model showed a trend towards higher STING expression compared with uninjured lungs, and STING protein expression co-localised with alveolar epithelium, indicating the involvement of STING in lung injury. Further, in the lung organoids stimulated with diABZI, we observed higher IL-6 (paired t-test; p < 0.05) levels and upregulated interferon-stimulated genes, as well as an upregulation of cytoplasmic pattern recognition receptor signalling pathway, supporting our hypothesis.

Conclusions: Our results suggest that upregulation of the cGAS-STING pathway contributes to acute lung inflammation and DAD in ARDS and warrants further investigation as a potential treatment target for ARDS.

P229 The proportion of CD8+ T cell subsets is determined by infection site and correlates with clinical outcomes in the ICU

Y Zhao 1 , H Chen 2 , F Xu 1

1 The First Affiliated Hospital of Chongqing Medical University, Department of Critical Care Medicine, Chongqing, China, 2 The Second Affiliated Hospital of Chongqing Medical University, Department of Critical Care Medicine, Chongqing, China

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Introduction: T cells play a critical role in antifungal immunity across different infection sites. Reduced CD8⁺ T-cell levels have been linked to early mortality in invasive candidiasis and invasive pulmonary aspergillosis in ICU [1,2]. A recently identified antifungal pattern recognition receptor has also been shown to mediate CD8⁺ T-cell immunity in mucosal fungal infections [3]. However, the site-specific characteristics of CD8 + T-cell immunity in fungal infections remain unclear. This study investigates the heterogeneity of T lymphocyte and CD8 + T-cell subset profiles across infection sites and their association with outcomes in ICU patients with fungal infections.

Methods: A cohort of 500 ICU patients with fungal infections was analyzed. Infection sites—blood, respiratory tract, urinary tract, digestive tract, and others (skin/mucosal)—were compared against baseline characteristics using one-way ANOVA with Tukey’s post-hoc testing. Linear regression assessed associations between T lymphocyte levels and disease severity across infection sites.

Results: Patients with fungal infections exhibited significant differences in 28-day survival across infection sites ( p < 0.001, Figure, panel A), with the poorest outcomes in blood and respiratory tract cases. T lymphocyte counts ( p = 0.004) and CD8⁺ T-cell ( p = 0.019) were significantly reduced in blood and respiratory tract cases (Figure, panel B). CD8⁺ T-cell levels correlated with SOFA and APACHE II scores in respiratory tract, and with SOFA scores and duration of mechanical ventilation in blood (Figure, panel C).

Conclusions: T lymphocyte counts were significantly suppressed in patients with fungal infections of blood and respiratory tract, with CD8⁺ T cells identified as the primary differential subset demonstrating significant associations with disease severity and clinical outcomes.

References Lass-Flörl C et al. Nat Rev Dis Primers 2024;10:20 Cui N et al. Crit Care 2013;17:R157 Charpak-Amikam Y et al. Nat Commun 2024;15:8664

Figure (abstract P229) A. 28-day survival analysis by infection sites (Kaplan–Meier curves). B. Distribution of T lymphocyte (including CD8 + and CD4 + T-cell) across infection sites (mean with 95% CI). C. Correlation of CD8⁺ T-cell proportion with clinical parameters in blood or respiratory tract infections (R 2 for goodness of fit)

P230 Leptin signaling and adaptive immunity in COVID-19 patients

A Bagul 1 , M Mura 2 , J Peltzer 2 , P Ponsin 3 , M Pissot 3 , T Martinez 1 , J Duranteau 1 , A Harrois 1 , N Libert 1 , A Huertas 4

1 Paris Saclay University Dynamic Lab, Le Kremlin-Bicêtre, France, 2 Institut De Recherche Biomédical Des Armées, Brétigny Sur Orge, France, 3 Service d’AnesthésieRéanimation, Hôpital d’Instruction des Armées Percy, Clamart, France, 4 Paris Saclay University Dynamic Lab, Medecine, Le Kremlin-Bicêtre, France.

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Introduction: During the coronavirus disease (COVID)-19 pandemic, overweight and obesity has emerged as one of the major risk factors for developing severe form of SARS-CoV-2 infection with poor outcome. It is well known that leptin, a cytokine-like hormone derived mainly from adipocytes, regulates a wide range of inflammatory and immune responses, by binding to its receptor ObR, but its role in COVID is still unclear. Hence, we are questioning here whether leptin signaling is involved in immune responses in COVID-19 patients.

Methods: We analyzed immune cells ObR expression in COVID-19 patients admitted in intensive care unit at Percy Hospital (n = 18; # NCT04365166 ) compared to healthy donors (n = 15). Blood was withdrawn at Day 1 and Day 14 after admission. Peripheral blood mononuclear cells (PBMCs) were stained with fluorescent antibodies against CD4, CD11b and ObR and analyzed by flow cytometry. Results are expressed as mean ± standard error of the mean (SEM) and with a statistical significance for one-way ANOVA test at p < 0.05.

Results: CD4 + cells number progressively decreased from Day 1 to Day 14 in COVID patients compared to healthy donors, whereas the expression of ObR in CD4 + cells increased overtime in patients compared to controls. At Day 1, 30 ± 6% of CD4 + c ells displayed high levels of ObR staining versus 43 ± 8% at Day 14, compared to 11 ± 3% in controls ( p < 0.05). On the opposite, CD11b + c ells increased overtime in COVID patients compared to controls, but ObR expression decreased in CD11b + cells in patients (7.8 ± 1% at Day 1 and 8.7 ± 2% at Day 14) compared to controls (14 ± 1%, p < 0.05).

Conclusions: ObR is differently expressed in immune cells in COVID-19 and varies overtime depending on cell phenotype. Our results suggest that leptin signaling may be involved in both innate and adaptive immune responses, with cell-type specificity in COVID-19. Further studies are needed to investigate the role of leptin signaling pathway in SARS-CoV-2 infection.

P231 Epithelial–macrophage metabolic crosstalk drives ACSF2 lactylation–mediated ferroptosis in ventilator-induced lung injury

M Ling 1 , F Yang 1 , X Xie 1 , Y Jiang 1 , H Luo 1 , J Lin 1 , E Chang 1 , L Pan 1 , L Ye 2

1 Department of Anesthesiology, Nanning, China, 2 Department of Anesthesiology, Guangxi Medical University Cancer Hospital, Nanning, China

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Introduction: Mechanical ventilation (MV) is a life-saving intervention for acute respiratory distress syndrome (ARDS) patients [1]. However, MV may paradoxically induce or worsen lung injury—ventilator-induced lung injury (VILI) [2]—increasing morbidity and mortality in the ICU. The met.abolic mechanisms driving VILI remain poorly understood. We hypothesized that dysregulated lactate metabolism promotes macrophage ferroptosis through protein lactylation.

Methods: Plasma lactate and PaO₂/FiO₂ were evaluated in VILI patients. A murine VILI model was established. Single-cell transcriptomics and NicheNet ligand–receptor analysis were used to characterize epithelial–macrophage signaling. In vitro studies included co-culture of macrophages with mechanically stretched alveolar epithelial cells or recombinant mucin 1 (MUC1) stimulation. Lactyl-proteomics identified modified proteins. Functional validation involved ACSF2 K510R mutation, SiglecE neutralizing antibody, and ferrostatin-1.

Results: Lactate elevation correlated negatively with oxygenation (r = –0.871). Lactate also accumulated in murine VILI lungs. Macrophages were the predominant lactate-producing population. Stretched epithelial cells released MUC1, activating macrophage SiglecE and downstream Ca2⁺–CaMKII–HIF1α signaling, enhancing glycolysis. Lactyl-proteomics identified ACSF2 lactylation at lysine 510, which increased significantly despite unchanged total ACSF2. ACSF2 K510 lactylation promoted ferroptosis and inflammation. Disruption of MUC1–SiglecE signaling, ACSF2 K510R mutation, or Ferrostatin-1 treatment significantly reduced ferroptosis and attenuated lung injury.

Conclusions: An epithelial–macrophage metabolic communication axis drives ACSF2 lactylation–mediated ferroptosis in VILI (Figure). ACSF2 lactylation represents a promising therapeutic target for critically ill patients.

References De Jong A. Intensive Care Med 2019;45:1635–1638 Slutsky AS et al. N Engl J Med 2014;370:980

Figure (abstract P231) Epithelial–macrophage metabolic crosstalk drives ACSF2 lactylation–mediated ferroptosis in ventilator-induced lung injury

P232 EMR3 trajectories predict immune recovery and clinical outcomes in sepsis patients

Y Ma 1 , P Yu 2 , X Wang 3 , W Ni 2 , J Zhang 3 , J Zhou 4

1 Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Department of Clinical Laboratory, Hangzhou, China, 2 Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Zhejiang, China, 3 Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China, 4 Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Department of Critical Care Medicine, Zhejiang, China.

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Introduction: Accurate assessment of immune dysfunction is essential for managing sepsis in the ICU. Current biomarkers such as PCT, CRP, and CD64 only partially reflect the complex transition from hyper-inflammation to immune suppression. EMR3 (encoded by ADGRE3), a myeloid-restricted adhesion GPCR expressed on neutrophils, has recently emerged as a potential indicator of immune competence. Its clinical value in sepsis, however, remains unclear. Objective to investigate whether EMR3 expression and its dynamic changes can predict clinical improvement and immune recovery in septic patients.

Methods: In a prospective ICU cohort, 300 adult patients with sepsis underwent serial peripheral-blood sampling at D0, D1, D3, D5, and D7. EMR3 expression on circulating neutrophils was quantified using flow cytometry. Clinical outcomes, including 28-day mortality and organ failure trajectories, were recorded. EMR3 performance was compared against nCD64, CRP, PCT, and SOFA scores. Diagnostic accuracy was evaluated using ROC analysis, focusing on both static values and temporal changes.

Results: EMR3 expression was markedly reduced at sepsis onset and correlated with illness severity (SOFA, p < 0.001). Patients who improved demonstrated a significant rise in EMR3 during the first week, whereas persistently low EMR3 was associated with immune paralysis. The dynamic change D7-D0 achieved the highest prognostic accuracy (AUC 0.87), outperforming PCT, CRP, and nCD64.

Conclusions: Dynamic EMR3 monitoring provides meaningful insight into immune recovery in sepsis and surpasses conventional biomarkers in predicting clinical improvement. EMR3 may support precision immune phenotyping and guide individualized immunomodulatory or antimicrobial strategies in the ICU.

P233 Extracellular vesicle proteomics defines molecular subtypes of sepsis and links metabolic dysregulation to patient outcomes

Y Bi, X Song

Shandong Public Health Clinical Center, Department of Critical Care Medicine, Ji nan, China

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Introduction: Sepsis is a heterogeneous syndrome characterized by dysregulated host response to infection, leading to high morbidity and mortality [1]. Current clinical classifications fail to capture biological diversity, hindering precision management. Extracellular vesicles (EVs) carry abundant bioactive proteins and may reflect disease-specific molecular alterations [2]. This study aimed to identify molecular subtypes of sepsis and elucidate key proteomic signatures associated with severity and outcomes.

Methods: Serum EVs were isolated from 324 participants, including sepsis-only, sepsis with ARDS, sepsis with AKI, sepsis with both ARDS and AKI, and healthy controls. EVs were characterized by TEM, NTA, and Western blot for CD9, CD81, and TSG101. Proteins were analyzed by LC–MS/MS and processed via Spectronaut and R-based bioinformatics pipelines. Consensus clustering was used for molecular subtyping, and differential expression, KEGG, and SVM analyses were applied to identify metabolic pathways and prognostic markers.

Results: A total of 4,754 EV proteins were identified. CD81, FLOT1, FLOT2, HSP90AA1, and HSP90AB1 increased progressively with sepsis severity. Four molecular subtypes (S1–S4) were defined, with S1 (“Sep-mild”) showing high lymphocyte counts and S4 (“Sep-severe”) displaying elevated procalcitonin and septic shock incidence (Figure). KRT family proteins were enriched in Sep-mild patients, suggesting a protective role. Metabolic pathway proteins were markedly downregulated in severe and non-survivor groups. A panel of eight metabolic proteins achieved an AUC > 0.95 for risk discrimination, validated in an independent cohort.

Conclusions: EV proteomics enabled stratification of sepsis into biologically and clinically distinct subtypes. Metabolic dysregulation emerged as a central determinant of disease severity and survival, highlighting metabolism-targeted intervention as a promising therapeutic avenue for precision sepsis care.

References Singer M et al. JAMA 2016;315:801–10 Gong T et al. Transl Res 2024;270:66–80

Figure (abstract P233) Schematic overview of serum exosome proteomics identifying molecular subtypes of sepsis and linking metabolic dysregulation to disease severity and survival. LC–MS/MS–based EV proteomics defined four sepsis subtypes (S1–S4); metabolic protein downregulation was associated with severe subtypes and poor outcomes, highlighting metabolism as a potential therapeutic target in sepsis

P234 The divergent metabolomic landscape of COVID-19 and community acquired pneumonia

V Rapti 1 , S Foutadakis 2 , EJ Giamarellos Bourboulis 3 , K Dakou 2 , K Leventogiannis 3 , G Poulakou 1

1 National and Kapodistrian University of Athens, 3rd Department of Internal Medicine, Athens, Greece, 2 Hellenic Institute for the Study of Sepsis, Athens, Greece, 3 National and Kapodistrian University of Athens, 4th Department of Internal Medicine, Athens, Greece

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Introduction: The metabolomic profile has the potential to reflect the host status and discriminate between diseases such as COVID-19 and community acquired pneumonia (CAP), offering valuable insights into their unique pathophysiological mechanisms.

Methods: Patient samples were derived from two clinical trials: the SAVE trial (ClinicalTrials.gov identifier: NCT04357366 ), and the ACCESS trial (ClinicalTrials.gov identifier: NCT04724044 ). All patients met the Sepsis-3 definitions. Sampling was done before start of the study drug. Untargeted metabolomics experiments were performed using serum subjected to high-performance liquid chromatography coupled with mass spectrometry. The raw metabolomics data were analyzed using the MetaboAnalyst platform.

Results: Samples from 46 patients with CAP and 46 with COVID-19 matched for age, sex and Charlson Comorbidity Index were subjected to untargeted metabolomics experiments. A total of 3,555 metabolites were detected and differential analysis recovered more than 70% of the metabolome as altered between conditions. Metabolite pathway analysis highlighted pathways related to the citric acid cycle and arachidonic metabolism as activated in CAP, while COVID-19 was mainly driven by alterations in amino acid metabolism and metabolites related to mitochondrial function (Figure).

Conclusions: Extensive divergence was observed in the metabolomic landscape of patients with COVID-19 or CAP, underscoring the disease-specific metabolic adaptations associated with viral versus bacterial pneumonia and providing potential targets for diagnostic and therapeutic development.

Figure (abstract P234) Metabolite set enrichment analysis for metabolites with increased levels in COVID-19 samples

P237 Pooled purified buffy coats to enhance extracorporeal immune cell therapy: an ex vivo evaluation

S Brabandt 1 , S Doss 2 , J Altrichter 3 , B Heskamp 3 , C Augustin 3 , DA Reuter 1 , JC Schewe 1 , S Mitzner 4 , G Klinkmann 1

1 University Medical Center Rostock, Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Rostock, Germany, 2 Fraunhofer Institute for Cell Therapy and Immunology, Rostock, Germany, 3 ARTCLINE GmbH, Rostock, Germany, 4 University Medical Center Rostock, Department of Internal Medicine / Clinic for Infectious Diseases, Nephrology, Endocrinology, and Tropical Medicine, Rostock, Germany

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Introduction: Buffy coats represent a promising approach for producing granulocyte concentrates for the extracorporeal immune cell therapy ARTICE, enhancing the clinical applicability to counteract sepsis-associated immunoparalysis. Building on a purification process that extends the 24-h shelf life of standard granulocyte preparations to 4 days, the use of buffy coats further improves production feasibility through broad availability. In this ex vivo study, we evaluated the performance of purified granulocyte concentrates from twenty pooled buffy coats (ppGC20) within the ARTICE-system.

Methods: ppGC20 were produced by pooling twenty ABO-identical buffy coats and applying a specialized purification protocol. The ARTICE-system includes a blood circuit and a separate plasma circuit. Before circulation, ppGC20 is introduced into the plasma circuit and retained by a cell filter. Only patient plasma contacts the immune cells before returning to the blood circuit. A plasma pool served as patient simulation. Circulation was maintained for 6 h and viability, functional activity, and metabolic parameters were assessed.

Results: Circulation remained stable over 6 h without technical issues. After 6 h, cell viability and phagocytic activity were maintained at ≥ 80%. Cytokine analyses showed that Eotaxin decreased significantly, while G-CSF, MCP-1, M-CSF, and TNF-a concentration increased significantly. Reduced glucose, elevated lactate, and a corresponding pH decline indicated metabolic activity.

Conclusions: ppGC20 are readily available immune cell preparations with stable functional performance within the ARTICE system. Cytokine shifts demonstrated active immunomodulation under ex vivo conditions. Due to their availability and functional stability, buffy-coat–derived granulocytes hold strong potential for clinical use in the ARTICE-system targeting sepsis-associated immunoparalysis.

P238 Manual lymphatic drainage to improve the outcome of patients after septic shock (MADAME trial): a safety and feasibility pilot randomized controlled trial

R Kula Jr. 1 , R Kula 2 , O Jor 2 , Y Vantuchová 3 , L Krupová 3 , J Mutka 3 , K Liszková 2

1 Department of Anaesthesiology, Resuscitation and Intensive Medicine, Tomas Bata Regional Hospital, Zlin, Czech Republic, 2 Department of Anaesthesiology, Resuscitation and Intensive Medicine, University Hospital Ostrava, Ostrava, Czech Republic, 3 Department of Dermatology, University Hospital Ostrava, Ostrava, Czech Republic

Critical Care 2026, 30 (Suppl 1): P238

Introduction: Impaired resolution of inflammation after initial treatment of septic shock contributes to persistent organ dysfunction and prolonged ICU stay. Supporting lymphatic drainage may help accelerate recovery of organ function. This pilot randomized trial ( NCT05874895 ) evaluated the feasibility and safety of manual lymphatic drainage (MLD) in the ICU setting.

Methods: Patients with treated septic shock (Sepsis-3), weaned off circulatory support and without SOFA improvement, were randomized to the MLD or the control group (Figure, panel A). MLD was performed daily for five days (30 min with two lymphotherapists or 60 min with one), in the supine position, including the head, neck, thorax, abdomen and extremities. Analysis was done on an intention-to-treat basis. Missing SOFA scores due to death or discharge were imputed using last observation carried forward.

Results: Thirty patients were randomized (15 MLD, 15 control). Baseline characteristics at randomisation (age, SOFA score, procalcitonin, interleukin-6, lactate, infection source, mechanical ventilation) were comparable. In the MLD group, 71 of 75 planned sessions were completed; missed sessions were due to temporary patient absence. No interference with routine nursing care was observed. Blood pressure, heart rate, and SpO₂ remained stable before and after MLD. SOFA trajectories are shown in the Figure, panel B. In the control group, early deaths led to missing SOFA scores (one on day 3 and four on day 5). Delta SOFA (day 0–5), expressed as median (min–max), was − 5.0 (− 10.0 to 1.0) in the MLD group versus − 1.0 (− 8.0 to 4.0) in the control group ( p = 0.032). The 28-day mortality was similar between groups (MLD: 5/15 vs control: 7/15, p = 0.710).

Conclusions: MLD appears feasible and safe in patients with septic shock and impaired resolution of organ dysfunction and leads to a significantly greater SOFA score reduction.

Figure (abstract P238) Study protocol (A) and individual SOFA trajectories (B)

P239 Novel subphenotypes of HRV in sepsis and prediction model

FEI Han

Zhongshan Hospital, Fudan University, Department of Critical Care, Shanghai, China

Critical Care 2026, 30 (Suppl 1): P239

Introduction: The autonomic nervous system (ANS) serves as the body’s unconscious control mechanism for vital physiological functions and ensuring homeostasis. The integration of ANS monitoring and targeted therapeutic interventions represents a paradigm shift in sepsis management. The aim of this study was to investigate the correlation between autonomic nervous system (heart rate variability, HRV) subtypes and clinical outcomes in patients with sepsis.

Methods: This retrospective study included 178 sepsis patients. Relevant medical history data and HRV data within 24 h of ICU admission were collected. K-means clustering was used to perform subtype analysis based on HRV data. Clinical outcomes were observed for different subtypes, with primary endpoints being the 28-day mortality rate. We established the prediction model based on the cluster, medical history and disease severity in this population, and evaluated the model using AUC and calibration. Data analysis was conducted using R.

Results: Based on HRV indicators (including time-domain and frequency-domain analyses), K-means clustering divided the 178 sepsis patients into two groups: C1 (144 cases) and C2 (34 cases). Significant statistical differences were found between the two groups for 28-day mortality (41.2% vs. 15.28%, p < 0.001), ICU mortality (38.2% vs. 11.8%, p < 0.001), and MV days (15.32 days vs. 5.56 days, p < 0.001). Kaplan–Meier curves showed significant differences between clusters. In the prediction model, nomogram indicated diabetes, COPD, HRV cluster and APACHE II score showed statistical significance. AUC curve and calibration curve showed the model performed well.

Conclusions: Sepsis patients can be divided into two subtypes based on HRV indicators using K-means clustering. The C2 group had poorer clinical outcomes. The prediction model with the cluster and medical history performed well in sepsis. HRV subtypes may serve as a direction for further clinical trials or future treatments.

P240 Differential resistance and disease tolerance pathway expression in sepsis subtypes and sterile inflammation

R Hoekstra 1 , A Chowdhury 2 , M Fish 3 , J N Kennedy 2 , C Seymour 2 , M Shankar-Hari 1

1 University of Edinburgh, Institute for Regeneration and Repair, Edinburgh, UK, 2 University of Pittsburgh, Department of Critical Care Medicine, Pittsburgh, USA, 3 Harvard Medical School, Massachusetts General Hospital and Harvard Medical School, Boston, USA

Critical Care 2026, 30 (Suppl 1): P240

Introduction: Infections and sterile tissue injury share host response pathways [1] of resistance to eliminate pathogen or damaged tissue (R-programs) and disease tolerance (host adaptations to survive (T-programs). We tested whether SENECA clinical subtypes of sepsis are detectable in sterile inflammation post cardiac surgery and report differences in R- and T-programs between SENECA subtypes.

Methods: Our prospective cohort (n = 97) consisted of adults with critical illness from (a) infection (sepsis) and (b) sterile inflammation post cardiac surgery (post-surgery) [2]. We used the published clinical classifier [3] to assign SENECA subtypes (α, β, γ, and δ). Sample-level enrichment analysis (SLEA) of panleukocyte transcriptome quantified (up or downregulation) of Hallmark pathways mapping to R- and T-programs at individual patient level, with hierarchical clustering for differences between SENECA subtypes.

Results: The α-type was least prevalent (8.2% in sepsis vs 4.1% in post-surgery), γ-type most prevalent (37.1% in sepsis vs 16.5% in post-surgery) and notably δ-type only seen in sepsis (11.3%). SLEA identified two clusters: cluster-2 (59%) with concurrently upregulated and cluster-1 (41%) with downregulated Hallmark pathways mapping to R- and T-programs. Cluster-2 consisted of predominantly sepsis patients (78.9%), while cluster-1 had similar proportions of sepsis and post-surgery patients (55% vs 45%). SENECA subtypes were distributed evenly across the two SLEA clusters, with α-type showing significantly higher expression of R- and T-programs than β, γ, and δ, explaining better outcome in SENECA study.

Conclusions: We report similarities in Hallmark pathways mapping to R- and T-programs between sepsis and sterile inflammation, with differences between SENECA sepsis subtypes, indicating subtype specific mechanisms may exist.

References Cohn O et al. Cell Syst 2022;13:1002–1015 Fish M et al. J Intensive Care Soc 2022;3:318–24 Seymour C et al. JAMA 2019;321:2003–2017

P241 Clustering transcriptomic trajectories in sepsis using dynamical systems cost-fitting landscapes (DSCL)

DA Striegel 1 , M Fazli 1 , JG Chenoweth 1 , D Bishop 2 , N Adams 2 , DV Clark 1

1 Henry M. Jackson Foundation for the Advancement of Military Medicine HJF, ACESO, Hesda, USA, 2 Naval Medical Research Command, Naval Medical Research Command, Silver Spring, MD, USA

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Introduction: Sepsis is a life-threatening condition caused by a dysregulated immune response to infection. Significant heterogeneity in its clinical and molecular representation creates challenges for the treatment and prognosis of sepsis. Here, Dynamical Systems Cost-fitting Landscape (DSCL), which uses a ordinary differential equation (ODE) model to characterize the temporal dynamics of gene-pattern interactions was used to cluster transcriptomic trajectories in sepsis revealing multiple common temporal paths.

Methods: Previously, the ACESO program at HJF collected 573 peripheral blood RNA samples from a Ghanaian cohort of 120 suspected sepsis patients and 42 healthy donors. Gene expression data (26,467 genes per sample) was reduced to 30 gene patterns using the Coordinated Gene Association in Pattern Sets (CoGAPS). Here, DSCL was used to characterize the temporal dynamics of gene-pattern interactions, calculate trajectory similarity through cost-fitting landscapes across model parameter space, and cluster these trajectories using the Multi-layer Bundling (MLB) technique.

Results: After applying the DSCL method to the longitudinal gene expression patterns, multiple clusters of trajectories were found. These clusters illustrated multiple failure pathways among non-survivors and heterogeneous recovery paths among survivors. Comparisons with clinical data collected at enrollment time showed significant differences in severity scores and immune system biomarkers across clusters. These results highlight the ability of DSCL to capture biologically and clinically relevant distinctions between clustered trajectory types.

Conclusions: DSCL clustered longitudinal gene expression patterns providing a powerful framework to develop more effective, personalized treatment strategies tailored to individual patient trajectories. This versatile methodology is not limited to sepsis and holds potential to advance the understanding of other complex diseases and dynamic biological processes.

P242 Droplet digital PCR-guided antibiotic use for critically ill patients with bloodstream infections: a retrospective observational study

HY Xiong 1 , YK Zhu 1 , KX Wang 1 , B Wang 1 , Y Kang 2

1 West China Hospital, Sichuan University, Department of Critical Care Medicine, Chengdu, China, 2 West China Hospital, Sichuan University, Chengdu, China

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Introduction: Bloodstream infections (BSIs) are a significant cause of morbidity and mortality in critically ill patients. Conventional blood cultures (BCs) are limited by low sensitivity and prolonged turnaround time, often necessitating the initiation of broad-spectrum antibiotic use. Droplet digital PCR (ddPCR) offers rapid and high-sensitivity pathogen detection; however, its clinical utility in guiding antimicrobial therapy has not been fully established.

Methods: This retrospective observational study included the adult patients who admitted to the ICU with clinical evidence of BSIs from October 2020 to August 2024. We compared the diagnostic performance and turnaround time of ddPCR against BCs. Additionally, we assessed how ddPCR results affected antimicrobial management, focusing on escalation, de-escalation, or confirmation of empirical therapy. Clinical outcomes, such as 28-day mortality and Sequential Organ Failure Assessment (SOFA) scores were compared.

Results: A total of 201 patients were included in this study. The cumulative mortality rate within 28 days was 40.3%. Compared with BCs, ddPCR showed a significantly higher positive rate (96.0% vs. 27.4%, p < 0.001), detecting 325 pathogens, including multidrug-resistant strains. The turnaround time for ddPCR was 8.57 h shorter than that of BCs ( p < 0.0001). Based on ddPCR results, antibiotic therapy was altered in 50.75% of patients (31.34% were escalated, 5.97% were de-escalated, and 13.43% confirmed empiric therapy). No significant differences were observed in 28-day mortality (HR = 1.46; 95%CI, 0.95–2.23; p = 0.072) (Figure) and SOFA scores ( p = 0.86) between the groups.

Conclusions: Droplet digital PCR has great potential in the early detection of BSIs. Antibiotic treatment guided by ddPCR had no adverse effect on patient prognosis.

Figure (abstract P242) Kaplan–Meier curve for 28-day mortality in suspected BSIs

P243 Comparative performance of the T2Bacteria Panel and conventional blood cultures in ICU patients with suspected sepsis

N Kangrga 1 , D Unic Stojanovic 1 , I Cirkovic 2 , I Malesevic 1 , M Bojic 3

1 Institute for Cardiovascular Diseases Dedinje, Anesthesia and Intensive Care, Belgrade, Serbia, 2 Institute for Microbiology and Immunology, Faculty of Medicine, Belgrade, Serbia, 3 Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia

Critical Care 2026, 30 (Suppl 1): P243

Introduction: Sepsis remains a leading cause of morbidity and mortality worldwide, where timely and accurate pathogen detection is critical for improving outcomes. Conventional blood cultures are the gold standard but are limited by prolonged turnaround times and suboptimal sensitivity, often delaying targeted therapy [1].

Methods: We performed a retrospective observational study including 30 adult postoperative cardiovascular ICU patients who underwent simultaneous testing with the T2Bacteria Panel and conventional blood cultures. The aim of the study was to evaluate the accuracy of the T2Bacteria panel for the diagnosis of bacterial sepsis and its impact on patient management, in terms of duration of empirical therapy and switch to directed therapy.

Results: T2Bacteria detected all on-panel ESKAPE pathogens with 100% sensitivity and specificity, whereas blood cultures identified 75% of these infections (Table). Discordant findings occurred in 20% of patients. Five off-panel organisms ( Burkholderia cepacia and Staphylococcus epidermidis ) were isolated only by blood cultures. T2Resistance detected carbapenemase and ESBL genes in 40% of T2-positive patients. Median time-to-result was 4h for T2 vs 108h for blood cultures. Antimicrobial therapy was modified after T2 results in 60% of T2-positive patients.

Conclusions: The T2Bacteria Panel provides rapid, highly accurate detection of key bloodstream pathogens and enables earlier optimization of antimicrobial therapy compared with conventional blood cultures. While limited by sample size and single-center design, this study demonstrates that integrating T2Bacteria and T2Resistance into clinical workflows has the potential to improve sepsis management by bridging the critical gap between empirical therapy and definitive microbiological diagnosis.

Reference

Reinhart K et al. N Engl J Med 2017;377:414–417

Table (abstract P243) Diagnostic performance of T2 and blood culture

P244 Multidisciplinary analysis of causes and risk factors of increased mortality in invasive Streptococcus pyogenes infections: a prospective study

J Závora, G Kroneislová, V Adámková

General University Hospital in Prague, Clinical Microbiology and ATB Centre, Prague, Czech Republic

Critical Care 2026, 30 (Suppl 1): P244

Introduction: Streptococcus pyogenes (group A streptococcus, GAS) causes a wide spectrum of infections with various outcomes. In recent years, a global rise in the incidence of streptococcal infections – including invasive forms – has been observed. Potential explanations include changes in the pathogen itself (e.g., increased virulence), the possible emergence of the hypervirulent M1UK variant, and broader population-level changes.

Methods: The objective of our ongoing study is to evaluate additional biomarkers (ICIS score, lactate, myoglobin, heparin-binding protein [HBP], vascular endothelial growth factor [VEGF], and MR-proadrenomedullin), together with a detailed assessment of the immunological profiles of affected patients. Using next-generation sequencing (NGS), we aim to identify potential virulence determinants in Streptococcus pyogenes to improve our understanding of factors contributing to the high mortality associated with invasive GAS infections. These parameters will be compared between patients experiencing sepsis episodes and those with non-sepsis infection presentations (e.g., skin and soft tissue infections).

Results: This increasing incidence is also reflected in data from the General University Hospital in Prague. In 2018, 148 unique GAS isolates were recorded; in 2019, 135 isolates; compared with 494 isolates in 2023 and 303 in 2024. Between 2020 and 2025, a concerning global upward trend in mortality associated with invasive GAS infections has also been observed. According to our previous analysis, mortality in our setting in 2016–2019 was 17.7%, whereas in 2020–2024 it increased to 42.6%.

Conclusions: The results of this study are expected to clarify the host and pathogen factors associated with severe disease progression. By integrating biomarker profiling with genomic characterization of circulating strains, we aim to identify indicators that may support earlier risk stratification and targeted clinical management.

P245 A prediction model for causative pathogens in bloodstream infection: development and validation using machine learning

L Liu

Xiangya Hospital, Central South University, Department of Critical Care Medicine, Xiangya Hospital, Central South University, China., Changsha, China

Critical Care 2026, 30 (Suppl 1): P245

Introduction: Early prediction of bloodstream infections (BSI) pathogens is important for earlier and appropriate administration of antibiotics [1]. This study aimed to develop a prediction model based on routinely available clinical and laboratory parameters for early identification of causative pathogens in patients with suspected BSI [2].

Methods: Predictors were initially selected from public available medical databases and subsequently calibrated using our database to optimize model parameters. Vital signs at the time of blood culture sampling and laboratory parameters within 24 h before or after sampling were collected from patient medical records. Next-Generation sequencing (NGS) was performed on simultaneously collected blood specimens from a subset of patients. Blood culture results were compared with NGS findings, and a predictive model was subsequently developed based on the analyzed data.

Results: The blood culture-positive (BCP) group and NGS-positive (NGSP) group showed different characteristics. Both groups showed lower lymphocyte count. The BCP group had lower mean arterial pressure and higher neutrophil percentage. The NGSP group exhibited higher levels of C-reactive protein and procalcitonin. The prediction model showed area under receiver-operating characteristics curve of 0.91, which demonstrated good discrimination of BSI. Furthermore, the model had a good performance at the identification of gram-positive bacteria. However, more work are warranted for further pathogen classification, such as gram-negative bacteria or fungi.

Conclusions: We developed a prediction model for BSI based on the daily available parameters that showed significant differences between BSI-positive and BSI-negative patients, which showed a good performance to predict BSI. Additionally, the model could identify certain pathogen of BSI, which would be helpful for early and appropriate antibiotics administration.

References Timsit JF et al. Intensive Care Med 2020;46:266–284 Bomrah S et al. Crit Care 2024;28:180

P246 Utility of molecular over traditional diagnostic methods in diagnosis and management of ventilator-associated pneumonia (VAP) caused by gram-negative bacteria in the intensive care unit

A Agrawal 1 , KP Agrawal 1 , S Agrawal 2 , S Prakash 1 , SSS Siddiqui 1 , S Misra 1

1 King George´s Medical University, Critical Care Medicine, Lucknow, India, 2 King George´s Medical University, Obstetrics Gynaecology, Lucknow, India

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Introduction: Ventilator-associated pneumonia (VAP) is a major ICU infection, often due to multidrug-resistant Gram-negative bacteria. Culture-based diagnostics are slow, delaying therapy, while molecular methods like real-time PCR enable rapid pathogen and resistance detection, potentially improving outcomes [1,2].

Methods: This 12-month prospective single-centre study in a 36-bed ICU enrolled 184 adults with suspected VAP. Group 1 (n = 92) underwent PCR plus culture, while Group 2 (n = 92) had culture alone. Data included demographics, clinical parameters, turnaround time, microbiology, antibiotic changes, SOFA/CPIS scores, and 28-/90-day mortality.

Results: PCR enabled faster detection (7.9 vs. 72 h), higher yield (98.9% vs. 96.8%), and better resistance gene identification. Despite lower specificity (10%), Group 1 had fewer ventilator days, shorter ICU stay, improved SOFA scores, and reduced 28-day (30.9% vs. 42.5%) and overall mortality (35.1% vs. 52.1%) (Table).

Conclusions: Integrating PCR with standard culture significantly improves early diagnosis and targeted therapy in VAP, leading to better clinical outcomes. Despite limitations in resistance detection specificity, PCR's rapid turnaround and high sensitivity support its role as a valuable adjunct in ICU infection management.

References Schubert S et al. J Clin Microbiol 2018;56:e01923-17 Buchan BW et al. Clin Infect Dis 2014;59 (Suppl 3):S134–S143

Table (abstract P246) Comparison of primary & secondary outcomes of both groups

P247 Heteroresistance in Pseudomonas aeruginosa and outcomes of nosocomial pneumonia: a preliminary prospective two-center study

S Nagle 1 , Q Leduc 1 , T Billard Pomares 2 , K Villageois Tran 3 , AC Maherault 4 , M Allain 4 , L Landraux 4 , JR Zahar 5 , D Roux 6 , K Chaibi 1

1 CHU Avicenne, Intensive Care Unit, Bobigny, France, 2 CHU Beaujon, Microbiology Department, Clichy, France, 3 CHU Avicenne, Microbiology Department, Bobigny, France, 4 CHU Louis Mourier, Microbiology Department, Colombes, France, 5 CHU Avicenne, Infection Prevention and Control Team, Bobigny, France, 6 CHU Louis Mourier, Intensive Care Unit, Colombes, France

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Introduction: Nosocomial pneumonia caused by Pseudomonas aeruginosa (PA) is frequent in the ICU and often associated with treatment failure. Heteroresistance (HR) is defined as the presence of a heterogeneous bacterial population with subpopulations exhibiting significantly higher MICs than the main population for the tested antibiotic. This study aimed to determine the prevalence of HR in PA pneumonia and to assess its association with clinical outcomes.

Methods: We conducted a prospective, observational, bicentric, preliminary study including all patients with a first episode of uncomplicated PA nosocomial pneumonia from October 2022 to March 2025. Heteroresistance was assessed using a disk-diffusion antibiogram performed on 10 distinct colonies (Figure); in borderline cases, HR was confirmed when subpopulation MIC was at least eightfold higher than MIC of the main population. We obtained an ethical approval (CLEA-2022–282).The primary composite endpoint (PCE) was treatment failure defined as, death, persistence, or recurrence of pneumonia within 28 days after the diagnosis of PA pneumonia. The association between HR and PCE was assessed using logistic regression adjusted for age and SOFA score at admission. Each component of the PCE was analyzed as a secondary outcome.

Results: Thirty-two patients were included; HR was present in 16/32 (50%). The PCE occurred in 21/32 patients (66%). After adjustment, no significant association was found between HR and the PCE (OR 0.82; 95%CI 0.07–9.96; p = 0.87). Among secondary outcomes, pneumonia persistence at day-28 was associated with HR (OR 7.00; 95%CI 1.18–41.36). No significant association was found with pneumonia recurrence or death, at day-28.

Conclusions: Heteroresistance is frequent in PA nosocomial pneumonia. No association was observed with the primary composite endpoint at day-28, whereas HR was associated with pneumonia persistence. These findings should be interpreted with caution due to the small sample size and the wide confidence intervals.

Figure (abstract P247) Disk diffusion with ceftazidime 10 μg in a clinical isolate of Pseudomonas aeruginosa shows inner-halo colonies within the inhibition zone, suggesting heteroresistance (HR) to ceftazidime. HR was confirmed by comparing the MIC of the inner-halo colonies with the MIC of the main population

P249 Infections related to central venous catheters in patients with hematologic disease before and after changes in institutional hygiene practices: a retrospective cohort study

M Lazarevic Lindblad, E Pålsson, V Lazarevic, O Borgquist, T Kander

Lund University, Department of Clinical Sciences, Lund, Sweden

Critical Care 2026, 30 (Suppl 1): P249

Introduction: To improve infection prevention of central venous catheters (CVC) in patients with hematological disease an Anti-Infection Double Lumen Bundle was introduced in December 2020 (implementation date), including replacement of the standard single lumen polyurethane catheter with a double lumen noble-metal alloy–coated CVC and switching to chlorhexidine-impregnated dressings. This study evaluated whether the Anti-Infection Double Lumen Bundle was associated with reduced catheter related infections.

Methods: All non-tunneled CVC insertions with a dwell time was ≥ 24 h, in adults (≥ 18 years), treated for hematologic disease between May 2013 and June 2024 were included. Data were extracted through automated electronic health record queries and manual review. Primary outcomes were suspected catheter-related infection (sCRI) and catheter-related bloodstream infection (CRBSI). Secondary outcomes were catheter tip colonization and infection rates per 1000 catheter-days.

Results: A total of 907 CVC insertions in 690 patients were analyzed (471 before and 436 after the implementation date). No significant differences were observed in sCRI (6.4% vs. 7.6%, p = 0.48), CRBSI (0.4% vs. 0.7%, p = 0.60), or catheter tip colonization (4.7% vs. 4.4%, p = 0.82) before versus after the implementation. Incidence rates per 1000 catheter-days did not differ (sCRI: 1.67 vs. 2.34, p = 0.20 and CRBSI: 0.11 vs. 0.21, p = 0.66). In multivariable analysis, no variables were associated with a higher incidence of sCRI, while antibiotic administration at insertion seemed protective (Table). The variable before vs after the implementation date was not associated with sCRI.

Conclusions: The introduction of the Anti-Infection Double Lumen Bundle did not reduce CVC-related infectious complications in hematology patients. Antibiotic at insertion was independently associated with sCRI. Further studies are needed to clarify optimal CVC type and preventive strategies in this high-risk population.

Table (abstract P249) Multivariable regression analysis for suspected catheter related infection

P251 Impact of colonization with Candidozyma auris on the outcome of ICU patients

L Herbel 1 , L Magdo 2 , C Vagner 1 , M Flonta 1 , V Briciu 2 , M Lupse 2

1 Clinical Hospital of Infectious Diseases, Cluj Napoca, Romania, 2 Clinical Hospital of Infectious Diseases, ‘Iuliu Hatieganu’ University of Medicine and Pharmacy, Cluj Napoca, Romania

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Introduction: In ICU populations, Candidozyma auris (CA) infection confers a significant clinical burden, characterized by extended hospitalization and elevated mortality, driven by its multidrug resistance and sustained environmental transmissibility. The objective of the study is to evaluate the impact of colonization and candidemia with CA on clinical outcome of patients in the ICU.

Methods: This retrospective study is based on electronic records of patients admitted during 1st of January 2024 – 30th of September 2025 in the medical ICU that received weekly fungal screening. Patients admitted in the ICU for invasive candidiasis and patients screened for colonization after positive blood cultures were excluded. Risk factors for CA infection were also analyzed. Data was collected and analyzed using jamovi (version 2.3).

Results: From 402 patients admitted in the ICU during the study period 81 (20.14%) were colonized with CA: 54 at admission, 27 during hospitalization—median of 9 days (IQR 7–20). The median age of the cohort was 77 years (IQR 67–82), 75 years (IQR 66.3 – 81) in the colonization at admission group and 82 years (IQR 73– 85.5) in the colonization during ICU stay ( p = 0.019). The RR for colonization in patients with previous healthcare contact was 2.41 (95% CI 1.15–5.06, p < 0.001). 9 patients developed CA fungemia at 14.9 days from positive screening (95% CI 3.59 – 26.2). The mortality rate in the cohort was 50%, with 44% in the colonized at admission and 63% in the second group ( p = 0.116). The mortality rate in the patients with CA fungemia in the cohort was 100%.

Conclusions: CA colonization and infection represent a key challenge in the ICU setting. Healthcare contact and hospitalization in ICU more than one week represent the most important risk factor for colonization. Patients who became colonized in ICU were older, with prolonged hospitalization, probably due to very strict infection control. Even if colonization had no impact on mortality rate, fungemia significantly decreased the survival.

P252 Comparison of mortality and clinical characteristics in cases of VAP due to monobacterial multidrug-resistant A. baumannii and K. pneumoniae

A Ciginskiene, D Adukauskiene

Lithuanian University of Health Sciences, Medical Academy, Kaunas, Lithuania

Critical Care 2026, 30 (Suppl 1): P252

Introduction: The type of causative pathogen in ventilator-associated pneumonia (VAP) due to multidrug-resistant (MDR) bacteria affects patient mortality [1]. This study aimed to compare 3, 7, 14, 30, 40, and 60-day mortality and clinical characteristics in patients with VAP due to monobacterial MDR A. baumannii (AB) vs K. pneumoniae (KP).

Methods: Retrospective data analysis of clinical characteristics and mortality in patients with monobacterial MDR AB and KP strains as pathogens of VAP over a 3-year period was carried out.

Results: Data of 141 monobacterial MDR VAP cases were evaluated: 105 (74.5%) due to AB, and 36 (25.5%) due to KP. The 3, 7, 14, 30, 40, 60 day mortality was 11 (10.5%), 21 (20.0%), 32 (30.5%), 60 (57.1%), 65 (61.9%), 65 (61.9%) in AB VAP cases, and 3 (8.3%), 3 (8.3%), 7 (19.4%), 10 (27.8%), 10 (27.8%), 10 (27.8%), in KP ones, all p < 0.001. Statistically significant differences of clinical characteristics in AB vs KP VAP were found in proportions of male 61 (58.1%) vs 32 (88.9%), p = 0.001, surgical admission 39 (37.1%) vs 25 (69.4%), p = 0.010, unconsciousness on ICU admission 15 (14.3%) vs 13 (36.1%), p = 0.005, use of IV antibiotics within 90 days before VAP onset 104 (99.0%) vs 28 (77.8%), p < 0.001, use of carbapenems 40 (38.1%) vs 3 (8.3%), p = 0.001, antifungals 16 (15.2%) vs 1 (2.8%), p = 0.048, presence of sepsis on VAP onset 93 (88.6%) vs 23 (63.9%), p = 0.001, and need of renal replacement therapy (RRT) during the ICU stay, 39 (37.1%) vs 6 (16.7%), p = 0.023.

Conclusions: All terms of mortality were higher in monobacterial MDR AB VAP cases. Patients with KP cases tended to die earlier (before 30 days). Mail sex, surgical admission, and unconsciousness were found to be associated with monobacterial KP VAP cases. However, in AB ones, there were previous antibacterial treatment, especially with carbapenems and antifungals, also sepsis on VAP onset, and renal failure with RRT.

Reference Sadigov A et al. J Lung Health Dis 2019;4:1157

P253 Secular trends in empiric antimicrobial treatment for severe community-acquired bacterial pneumonia in the United States

M Zilberberg 1 , M Greenberg 2 , B Nathanson 3 , Q Andan 4 , V Curt 2 , A Shorr 5

1 EviMed Research Group, LLC, Health Services Research, Goshen, USA, 2 Eagle Pharmaceuticals, Inc., Woddcliff Lake, USA, 3 OptiStatim, LLC, Longmeadow, USA, 4 EviMed Research Group, LLC, Goshen, USA, 5 Washington Hospital Center, Washington, USA

Critical Care 2026, 30 (Suppl 1): P253

Introduction: The COVID-19 pandemic precipitated a surge in misuse of broad-spectrum antimicrobials in community-acquired bacterial pneumonia (CABP), accelerating antimicrobial resistance (AMR). As a response, stewardship efforts to limit use of these overly broad antibiotics intensified. It remains unclear if these initiatives have impacted behavior.

Methods: We compared antibiotic prescribing for patients with severe CABP (sCABP) during two time periods, the first covering 2010–2015 [1] and the second 2021–24 (current analysis). Both analyses derived from the Premier Healthcare Database, and both defined sCABP by the IDSA/ATS major criteria, which require advanced respiratory or circulatory support or both. We compared baseline patient characteristics, empiric antibiotic selections, and hospital mortality.

Results: Among patients with CABP, the prevalence of sCABP was 14.1% (n = 21,805) initially and rose to 19.1% (n = 52,618) currently. Current cohort patients were older (mean age + SD 67.6 + 15.1 vs. 69.1 + 13.4 years), less likely male (51.7% vs. 49.7%), and less chronically ill (mean + SD Charlson comorbidity score 4.4 + 2.8 vs. 3.5 + 2.3). We observed a decrease in the frequency of early ICU admission (89.5% to 37.4%) and need for vasopressors (60.3% to 15.8%). The utilization of vancomycin (66.4% to 38.6%) and piperacillin/tazobactam (43.5% to 13.4%) fell substantially. Concomitantly there was an increase in the administration of ceftriaxone (35.9% to 60.3%) and azithromycin (31.9% to 49.4%). Hospital mortality went from 22.0% to 15.0%.

Conclusions: More patients presently receive empiric regimens for sCABP in accordance with both evidence-based guidelines and principles of antibiotic stewardship. The use of narrower spectrum agents indicates continued success of stewardship efforts nationally with the aim of containing the emergence of further AMR. Hospital mortality, though decreased, remains unacceptably high.

Reference Haessler S et al. Crit Care Med 2022;50:1063–1071

P254 Implementation of an antibiotic protocol for VAP prophylaxis in a neuro-ICU

F Daniele 1 , GM Mazza 2 , MC Laganà 1 , S Benedetti 1 , M Pagani 3 , A Guglielmi 4

1 Università di Pavia, Pavia, Italy, 2 Fondazione IRCCS Policlinico San Matteo, Anestesia e rianimazione 1, Pavia, Italy, 3 Fondazione IRCCS Policlinico San Matteo, Pavia, Italy, 4 Alma Mater Ticinensis Foundation of Pavia under the Progetto Professionalità, Pavia, Italy

Critical Care 2026, 30 (Suppl 1): P254

Introduction: The role of short-term antibiotic administration in Ventilator Associated Pneumonia (VAP) prophylaxis remains debated. Recently the PROPHY-VAP1 study has shown promising results by implementing a single dose of prophylactic ceftriaxone [1]. The aim of this study is to investigate if the routine implementation of such measure modifies clinical practice in patients with acute brain injury, in a tertiary hospital care of a high-income country.

Methods: This is a retrospective single centre observational study comparing two cohorts of patients with acute brain injury admitted to the ICU before (BC) and after (AC) the implementation of routine prophylactic ceftriaxone after intubation. We measured adherence to new protocol, VAP incidence, and antibiotic consumption as total days of antibiotic therapy (DOTs).

Results: We included in the analysis 124 patients (53 in the BC group, 71 in the AC group). No differences in terms of sex, age or severity were found between the cohorts, while rate of previous hospitalization higher in the AC group (29.6% vs 11.3%, p = 0.015). Adherence to new protocol was low (33%). VAP rates did not differ between the two cohorts, and the same was true for DOTs (10.63 ± 14.23 vs 13.85 ± 16.78, p = 0.25). We performed a secondary analysis inside the AC group comparing patients who actually received ceftriaxone vs those who didn’t, but the previous results were confirmed.

Conclusions: The implementation of protocolized prophylaxis with ceftriaxone did not reduce the total consumption of antibiotics. We hypothesize that such result was due to low adherence to the protocol, but further investigation is needed.

Reference Dahyot-Fizelier C et al. Lancet Respir Med 2024;12: 375–85

P256 Influenza A-associated pulmonary aspergillosis in patients admitted to the intensive care unit in China: a retrospective cohort study

M Xue 1 , Z Zhou 1 , R Zheng 2 , Y Yang 1 , H Qiu 1 , J Xie 1

1 Zhongda Hospital, School of Medicine, Southeast University, Department of Critical Care Medicine, Nanjing, China, 2 Jiangsu Province Hospital, Nanjing, China, Department of Critical Care Medicine, Nanjing, China

Critical Care 2026, 30 (Suppl 1): P256

Introduction: Invasive pulmonary aspergillosis (IPA) is a life-threatening complication increasingly recognized in critically ill patients with influenza, a condition known as influenza-associated pulmonary aspergillosis (IAPA). However, large-scale data on the incidence, risk factors, and impact of IAPA specifically in Influenza A patients from China are limited.

Methods: We conducted a retrospective, multicenter cohort study across 20 intensive care units (ICUs) in China. The study included adult patients with severe Influenza A pneumonia admitted between November 1, 2024, and February 28, 2025. Patients were categorized into IPA and non-IPA groups based on the FUNDICU diagnostic criteria. Demographics, clinical characteristics, and outcomes were compared. Multivariate logistic regression and Cox regression analyses were used to identify independent risk factors.

Results: Of 526 patients with severe Influenza A, 179 (34.0%) were diagnosed with IPA. Compared to non-IPA patients, those with IPA were younger (69 vs. 72 years, p = 0.017), had higher APACHE II scores (22 vs. 19, p = 0.007), and had a higher prevalence of diabetes (48% vs. 36%, p = 0.017). IPA was independently associated with diabetes (aOR 1.86, 95% CI 1.25–2.79), age ≥ 75 years (aOR 1.80, 95% CI 1.20–2.73), continuous renal replacement therapy (aOR 1.95, 95% CI 1.18–3.22), and corticosteroid use during the ICU stay (aOR 1.61, 95% CI 1.09–2.39). The 60-day mortality was significantly higher in the IPA group (47.5% vs. 32.9%, p = 0.001). Hematologic disorders (aHR 4.61, 95% CI 1.43–14.84) and elevated C-reactive protein levels (aHR 1.01 per unit increase, 95% CI 1.00–1.01) were independent risk factors for IPA mortality (Figure).

Conclusions: IPA is a frequent and fatal complication in critically ill patients with Influenza A in China, occurring in over one-third of ICU admissions. Key risk factors include diabetes, advanced age, organ support, and corticosteroid use. Increased awareness of risk factors and early mycological screening are crucial.

Figure (abstract P256) Left panel, Kaplan–Meier curves for 60-day survival between IPA and non-IPA; Right panel, Forest plot of multivariable logistic regression analysis identifying. Independent risk factors for IPA development among influenza A patients

P257 Financial benefit with clarithromycin treatment in hospital stay: an analysis of the ACCESS randomized clinical trial

V Rapti 1 , E Tasouli 2 , A Kotsaki 3 , G Niotis 4 , C Loutos 5 , E Christaki 6 , EJ Giamarellos-Bourboulis 3 , G Poulakou 1

1 National and Kapodistrian University of Athens, 3rd Department of Internal Medicine, Athens, Greece, 2 Thriasio General Hospital, 1st Department of Internal Medicine, Elefsis, Greece, 3 National and Kapodistrian University of Athens, 4th Department of Internal Medicine, Athens, Greece, 4 National and Kapodistrian University of Athens, 2nd Department of Propedeutic Medicine, Athens, Greece, 5 Hellenic Institute for the Study of Sepsis, Athens, Greece, 6 University of Ioannina, 2nd Department of Internal Medicine, Ioannina, Greece

Critical Care 2026, 30 (Suppl 1): P257

Introduction: In the ACCESS randomized controlled trial ( NCT04724044 ) addition of clarithromycin to standard-of-care (SoC) antibiotics provided substantial clinical benefit in adult patients hospitalized for community-acquired pneumonia (CAP), including early clinical responses and decrease of the need for mechanical ventilation and transfer to the Intensive Care Unit (ICU) [1]. We investigated the impact of clarithromycin treatment on the total cost of hospital stay.

Methods: Patients with CAP, total SOFA score 2 or more and blood procalcitonin 0.25 ng/ml or more were randomized to seven days of treatment with SoC and placebo or SoC and clarithromycin. The overall cost of hospital stay was explored using three approaches: a) the cumulative daily cost for 90 days; b) differences in per diem costs between groups; and c) the total cost of ICU stay.

Results: Substantial decrease of the cumulative cost was apparent as early as day 3 (Figure). Per-diem costs of hospital stay were 27.22 Euros less in the clarithromycin group. The mean (SE) cost of ICU stay was €931.2 (250.1) in the placebo arm and €191.8 (78.5) in the clarithromycin arm ( p : 0.005).

Conclusions: The addition of clarithromycin to SoC antibiotics substantially decreased the cost of management of hospitalized patients with CAP in the ACCESS trial. Reduction in ICU-related costs in the clarithromycin group was a major contributor to the overall savings. The ACCESS trial was funded by Abbott Products Operations which had no role in study design, data collection, data analysis, or data interpretation.

Reference Giamarellos-Bourboulis EJ et al. Lancet Respir Med 2024;12:294–304

Figure (abstract P257) Cumulative cost of CAP management the 90 days of follow-up n: number of patients; SE: standard error; SoC: standard-of-care

P258 Reproducing sepsis endotypes of interferon-gamma and immunoparalysis in animal models

P Koufargyris, E Karagianni, K Leventogiannis, EJ Giamarellos-Bourboulis.

National and Kapodistrian University of Athens, 4th Department of Internal Medicine, Athens, Greece

Critical Care 2026, 30 (Suppl 1): P258

Introduction: Functional classification recognizes two major sepsis endotypes: sepsis-induced immunoparalysis (SII) and IFNγ-driven sepsis (IDS) [1]. Given the lack of established preclinical models, we aimed to develop two mice models of SII and IDS.

Methods: 88 C57BL/6 mice (both sexes, < 16 weeks) were divided into 5 groups: A) intravenous challenge (IV) with phosphate buffered saline (PBS) followed by sham abdominal operation after five days (Sham), B) IV challenge with lipopolysaccharide (LPS) followed by Sham, C) IV PBS followed by 50% cecal ligation and puncture (CLP), D) IV LPS followed by CLP and E) IV challenge by Escherichia coli followed by CLP. Mice challenged by E.coli were resuscitated with antibiotics. Mice were sacrificed 48 h after surgery. Splenocytes and bone marrow cells were isolated and stimulated with LPS or heat-killed Candida albicans for the production of tumour necrosis factor-alpha (TNFα) and CXCL9.

Results: Splenocytes of the E.coli + CLP group were exhausted for TNFα production. LPS + CLP group exhibited most of CXCL9 in plasma and from bone marrow cells (Figure).

Conclusions: The combination of pre-treatment with E.coli followed by CLP can be used to model SII, while LPS + CLP can be used to model IDS.

Reference Giamarellos-Bourboulis EJ et al. eBioMedicine 2024;109:105414

Figure (abstract P258) CXCL9 in blood and production of CXCL9 and TNFα from splenocytes and bone marrow cells after stimulation

P259 Prospective validation of sepsis endotype classification: results from the EMBRACE trial

A Alevizou 1 , A Efthymiou 2 , A Lavrentieva 3 , E Antoniadou 4 , G Dimopoulos 5 , D Liatsi 6 , E Mouloudi 7 , S Sympardi 8 , A Ioakeimidou 9 , EJ Giamarellos-Bourboulis 1

1 National and Kapodistrian University of Athens, 4th Department of Internal Medicine, Athens, Greece, 2 AHEPA Thessaloniki General Hospital, Intensive Care Unit, Thessaloniki, Greece, 3 G. Papanikolaou Thessaloniki General Hospital, Intensive Care Unit, Thessaloniki, Greece, 4 G. Gennimatas Thessaloniki General Hospital, Intensive Care Unit, Thessaloniki, Greece, 5 National and Kapodistrian University of Athens, Intensive Care Unit, Alexandra Athens General Hospital, Athens, Greece, 6 Papageorgiou Thessaloniki General Hospital, Intensive Care Unit, Thessaloniki, Greece, 7 Ippokrateion Thessaloniki General Hospital, Intensive Care Unit, Thessaloniki, Greece, 8 Thriasion Elefsis General Hospital, 1st Department of Internal Medicine, Elefsis, Greece, 9 Asklipeion Voula General Hospital, Intensive Care Unit, Voula, Greece

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Introduction: A recent retrospective analysis of 5,503 septic patients across three countries identified four endotypes: macrophage activation-like syndrome (MALS); interferon-gamma driven sepsis (IDS); sepsis induced immunoparalysis (SII) and adaptive endotype [1]. EMBRACE ( NCT06694701 ) is an ongoing, multicentre, phase 2a, double-blind, randomised controlled trial investigating whether treatment with emapalumab improves outcomes for patients with interferon-gamma (IFNγ)-driven sepsis (IDS). Analysis of patients screened for eligibility provides prospective validation of the four endotypes.

Methods: Between March and October 2025, 374 patients who met the Sepsis-3 criteria were screened for eligibility. Blood samples were analyzed by flow cytometry for human leukocyte antigen-DR (HLA-DR) receptors expressed on CD45/CD14-monocytes, and by enzyme immunosorbent assay for ferritin, interferon-gamma (IFNγ) and CXCL9. The following definitions were applied: macrophage activation-like syndrome (MALS) as ferritin > 4,420 ng/mL; interferon-gamma driven sepsis (IDS) as the combination of ≥ 8,000 HLA-DR receptors with detectable IFN-γ and CXCL9 > 2,200 pg/mL; sepsis induced immunoparalysis (SII) as < 8,000 HLA-DR receptors; and the adaptive endotype as ≥ 8,000 HLA-DR receptors with detectable IFN-γ and CXCL9 < 2,200 pg/mL.

Results: The distribution across the four sepsis endotypes is presented in the Figure: MALS, n = 14 (3.7%); IDS, n = 74 (19.8%); SII, n = 154 (41.2%); adaptive endotype, n = 132 (35.3%). Among patients with SII, 14 patients (3.7%) exhibited elevated CXCL9. Classification within 6–12 h of blood sample collection was achievable, demonstrating the feasibility of real-time endotype determination and supporting the potential for timely, targeted therapeutic interventions.

Conclusions: The described frequency of sepsis endotypes [1] was prospectively validated and confirmed using the screening data from the EMBRACE trial.

Reference Giamarellos-Bourboulis EJ et al. eBioMedicine 2024;109:105414

Figure (abstract P259) Distribution of sepsis endotypes in the EMBRACE trial. Patients are classified into four endotypes: MALS, IDS, SII and adaptive. The overlap between MALS and IDS is provided. Abbreviations: IDS, interferon-gamma (IFNγ)-driven sepsis; MALS, macrophage activation-like syndrome; n, number of patients; SII, sepsis-induced immunoparalysis

P260 Integrating inflammatory and endothelial biomarkers in machine learning models for predicting sepsis development in critically ill patients

I Papapanagiotou 1 , AG Vassiliou 2 , V Giannopoulou 3 , A Karalis 1 , Z Mastora 4 , S Kokkoris 3 , S Golemati 3 , O Kampouropoulou 3 , CS Vrettou 3 , I Dimopoulou 3

1 IB Hellas, Athens, Greece, 2 National and Kapodistrian University of Athens, 1st Department of Critical Care Medicine Pulmonary Services, GP Livanos and M Simou Laboratories, Athens, Greece, 3 National and Kapodistrian University of Athens, Athens, Greece, 4 General Hospital of Thoracic Diseases Sotiria, Athens, Greece

Critical Care 2026, 30 (Suppl 1): P260

Introduction: Sepsis mortality remains high despite advances in research and clinical care, making accurate prediction crucial. Using machine learning (ML) methods, we developed models that, apart from vital signs and routine blood parameters, incorporate inflammatory and endothelial markers and compared their performance against traditional clinical scoring systems.

Methods: Our retrospective dataset contained 480 patients hospitalized in the intensive care unit (ICU) of Evangelismos Hospital. The patients were non-septic on admission, while 43 developed sepsis during ICU stay. Interleukin (IL)-6 and soluble endothelial protein C receptor (sEPCR) were measured by ELISA. Single time points upon ICU admission (first 24-h) were recorded and used as input for the ML models. Missing value imputation was handled natively by the models. Recursive feature elimination was used to select the final set of 37 features. The ML algorithms Random Forest (RF), XGBoost (XGB), LightGBM (LGBM), and Ensemble (RF, XGB, LGBM) were used. SHapley Additive exPlanations (SHAP) was used to explain the model output.

Results: Our best performing model in numerical metrics was the Ensemble model, achieving 91.48% AUC (85.80–96.46, 95% CIs). The top 10 ranked features in Gini feature importance rankings were IL-6, procalcitonin, sEPCR, lymphocytes (%), total bilirubin, albumin, C-reactive protein, hemoglobin, platelet count, and white blood cell count. Our model significantly outperformed traditional scoring systems such as SOFA and APACHE II scores ( p < 0.05) (Figure).

Conclusions: Our ML models integrating inflammatory and endothelial biomarkers demonstrated promising discrimination and higher numerical metrics than traditional clinical scoring systems for sepsis prediction. However, their clinical utility requires further validation through prospective, multicenter studies with larger datasets.

Figure (abstract P260) ROC curves for sepsis prediction. Pink line, our ML model; black line, SOFA score; blue line, APACHE II score

P261 Reinforcement learning for treatment decision-making in sepsis: a scoping review

ZY Tang 1 , PL Sun 1 , RT Liang 2 , SQ Tong 1 , Y Yang 1 , MC Yang 3 , H Chen 1

1 Southeast University, Department of Critical Care Medicine, Nanjing, China, 2 Chengdu University of Technology, College of Computer Science and Cyber Security, Chengdu, China, 3 The University of Hong Kong, Li Ka Shing Faculty of Medicine, Hong Kong, SAR China

Critical Care 2026, 30 (Suppl 1): P261

Introduction: Sepsis management involves sequential decisions that align with reinforcement learning (RL), yet current sepsis RL applications remain exploratory with methodological gaps. This scoping review characterises model construction, clinical tasks, and key limitations in the existing literature.

Methods: We systematically searched six databases and two preprint servers through 4 July 2025 and screened all records against pre-specified inclusion and exclusion criteria. The project was prospectively registered on OSF.

Results: Of the 1,515 records identified, 72 studies were included. Most focused on optimising vasopressor therapy and fluid resuscitation using retrospective ICU data (Table). Designs varied widely in states, actions, objectives, algorithms, and policy evaluation, with limited work on interpretability, generalisability, and safety.

Conclusions: RL is a promising tool for sepsis decision support, but evidence is early and heterogeneous, and key gaps and future directions are summarised in the Table.

Table (abstract P261) Summary of RL findings and future directions in sepsis care

P262 A digital twin model uncovers treatable traits and enable personalized treatment suggestions

L Mellhammar 1 , AM Scott 2 , E Malmström 2 , AG Gustafsson 2 , A Bakochi 3 , M Tirthankar 2 , L Thelaus 2 , F Kahn 2 , J Malmström 2 , A Linder 2

1 Faculty of Medicine, Lund University, Department of Clinical Sciences, Lund, Sweden, 2 Faculty of Medicine, Lund University, Lund, Sweden, 3 Swedish National Infrastructure for Biological Mass Spectrometry, Lund, Sweden

Critical Care 2026, 30 (Suppl 1): P262

Introduction: We have constructed a digital twin model based on clinical and proteomic data for sepsis stratification in patients with suspected sepsis using machine-learning. As patients with similar clinical features are adjacent in the digital twin model, we here explore molecular trajectories through the digital twin model to suggest therapeutically actionable pathways.

Methods: Patients in a testing cohort with suspected sepsis (n = 680) were split into a low-risk and a high-risk group depending on their estimated rate of developing sepsis using the digital twin model. The mean importance of the 10 most important proteins associated with predicting sepsis were identified. A pathway for individual patients in a validation cohort with suspected sepsis (n = 253) was extracted from an area in the digital twin model with poor outcome (i.e. where the neighbors have persistent organ dysfunction) to an area of good outcome (i.e. where the neighbors have low persistent organ dysfunction). The shortest path from the poor outcome to the good outcome areas were identified and its corresponding personalized molecular profile trajectories, based on the 10 proteins in the model (Figure).

Results: Most proteins were broadly associated with persistent organ dysfunction whereas some proteins displayed a more variable response. These proteins could act as direct targets for treatment or as proxy proteins that implicate their associated biological pathways as targets. Examples in our model are that lowering von Willebrand factor (VWF) and FGL1 levels are linked to better predicted outcomes. FGL1 is an immune checkpoint ligand for LAG-3 that drives T-cell dysfunction. Excess VWF with reduced ADAMTS13 activity promotes thrombosis and multi-organ dysfunction. Targeting these trajectories may benefit high-VWF or FGL 1 patients.

Conclusions: These findings demonstrate that molecular digital twin models can identify potential therapeutically actionable pathways associated with persistent organ damage for certain patients at the time-of-admission.

Figure (abstract P262) A selected representation of an extracted pathway of a new patient

P265 Procalcitonin and C-reactive protein and their correlation as predictive markers of positive cultures in neurocritical patients during the orotracheal intubation phase in an intensive care unit of a hospital in Northeast Mexico

LGD Gaucin Delgado, MRR Rodriguez Reyna, L Velasco Morales, GA Aguirre Gomez, OI Aguilera Olvera, JA Villalobos Silva

Hospital Regional de Alta Especialidad Ciudad Victoria, Tamaulipas, ICU, Ciudad Victoria, Mexico

Critical Care 2026, 30 (Suppl 1): P265

Introduction: In neurocritical patients undergoing orotracheal intubation, the main complication is ventilator-associated pneumonia. This condition increases morbidity and mortality; therefore, a retrospective study was conducted to evaluate the correlation between C-reactive protein (CRP) and procalcitonin—our most accessible acute-phase reactants—and the development of infectious agents identified through bronchial secretion or sputum cultures.

Methods: A retrospective descriptive study was performed using clinical records from 34 orotracheally intubated patients during the 2023–2024 period. Demographic, laboratory, and microbiological data were collected and analyzed using descriptive statistics.

Results: Of the 34 patients included, 18 had positive bronchial cultures. Those with positive cultures had a mean CRP of 91.15 mg/dL, whereas the 16 patients with negative cultures had a mean CRP of 86.09 mg/dL (Figure). Procalcitonin levels averaged 18.78 ng/mL in patients with positive cultures versus 20.09 ng/mL in those with negative cultures. These findings indicate no correlation of these markers and the presence of a positive culture. No meaningful differences were observed between marker levels and culture positivity.

Conclusions: No correlation was identified between procalcitonin, C-reactive protein, and the presence of positive cultures.

Figure (abstract P265) Comparison of mean in CRP and procalcitonin level and culture results

P266 Validating pancreatic stone protein for early sepsis detection and outcome prediction in community acquired infections: evidence from a tertiary medical center

C Michailides 1 , M Lagadinou 1 , T Paraskevas 2 , K Papantoniou 3 , EK Velissari 1 , E Georgopoulou 1 , N Polychronopoulos 1 , E Kechagia 1 , D Velissaris 1 , M Marangos 1

1 University Hospital of Patras, Internal Medicine, Patras, Greece, 2 University Hospital of Patras, Nephrology, Patras, Greece, 3 University Hospital of Patras, Gastroenterology, Patras, Greece

Critical Care 2026, 30 (Suppl 1): P266

Introduction: Evaluation of pancreatic stone protein (PSP) is effective and possibly inferior to other commonly used biomarkers in predicting unfavorable outcomes in multiple infections and sepsis. We aim to validate PSP in patients with community acquired infections to establish its role in point-of-care setting.

Methods: Adult patients consecutively admitted to the Emergency Department (ED) of a tertiary medical center, with the diagnosis of intra-abdominal infection (IAI), urinary tract infection (UTI) or lower respiratory tract infection (LRTI) who met the inclusion criteria were enrolled. PSP was measured in whole blood, within one hour since admission, by spectrophotometry using abioSCOPE device. Statistical analysis was performed, and a cut-off value for PSP to predict the composite outcome of sepsis, readmission, antibiotic treatment escalation and need for invasive treatment was estimated. Patients were followed for 28 days to document their outcomes.

Results: A total of 101 patients were included. 52.5% had LRTI, 36.6% had UTI and 18.8% had IAI, 12.9% > 1 infection site. Our primary outcome met statistical significance, as PSP predicted the composite outcome of sepsis, readmission, antibiotic treatment escalation and need of invasive treatment with an area under curve (AUC) = 0.844 (95% CI 0.767–0.920), in the optimal cut-off of 48.5 ng/dL (Figure). PSP predicted sepsis with an AUC = 0.892 (95% CI 0.826–0.956) and was also an independent risk factor for sepsis and mortality after age adjustment. PSP outscored other sepsis biomarkers for sepsis and the composite outcome. It was also correlated with SOFA day 1, SOFA peak and qSOFA independently of renal function.

Conclusions: PSP is a valuable biomarker that can rule out sepsis and identify low-risk patients, giving insights regarding their clinical management. It outperforms other sepsis biomarkers and relates with frequently used severity assessment scores, such as SOFA. In the ED, PSP can identify infected patients at high risk for sepsis despite low qSOFA scores.

Figure (abstract P266) A. AUROC of PSP on prognostic accuracy of sepsis, B. AUROC of PSP on prognostic accuracy of the composite outcome of sepsis, readmission, treatment escalation and invasive treatment

P267 Heparin binding protein in sepsis. A comprehensive overview of pathophysiology, clinical usage and utility as biomarker

C Michailides, F Tasouli, E Georgopoulou, C Chatzigrigoriadis, N Polychronopoulos, E Kechagia, EK Velissari, M Lagadinou, D Velissaris

University Hospital of Patras, Internal Medicine, Patras, Greece

Critical Care 2026, 30 (Suppl 1): P267

Introduction: Heparin binding protein (HBP) is an enzymatically inactive protein of the serine protease family which dramatizes important role in host response to stress, especially infection and sepsis. It is produced by activated neutrophils due to a variety of stimuli and is part of the immune response that leads to macrophage, lymphocytes and neutrophils activation and monocytes adhesion (Figure). Its most common repository is the azurophilic granules of the neutrophils.

Methods: A PubMed search was conducted between November 2024 and February 2025 using the following terms: ((heparin binding protein OR HBP) and (sepsis OR pathophysiology OR prognosis OR diagnosis)). All types of studies were potentially eligible for inclusion in this review. We excluded expert opinions, studies referring to child population and animal studies.

Results: HBP has been studied as a biomarker for several infections, including central nervous system infection, respiratory tract infection and urinary tract infection and in several settings, including Emergency Department and Intensive Care Unit, with promising results. As a biomarker for infection and sepsis, HBP has been compared to other commonly used biomarkers such as neutrophil to lymphocyte ratio, white blood count, C-reactive protein and procalcitonin, with at least comparable performance. Its sharp increase is promising for the early detection of sepsis.

Conclusions: Heparin binding protein is a promising biomarker for sepsis and infection because of the ability to differentiate inflammatory conditions from infections and bacterial from non-bacterial causes of infection. The sepsis-related organ damage, as it is represented by Sequential Organ Failure Assessment score can also be reflected by the proportional to the score, HBP increase. Thus, it could serve as an early detector of sepsis and stratify patients causatively and according to their organ dysfunction risk. Consequently, HBP could be a helpful and promising biomarker for sepsis and infection.

Figure (abstract P267) HBP pathophysiology and its role in innate immunity and response to infection

P269 Prognostic performance of IL-6 and STREM-1 compared with conventional markers in adults with sepsis and septic shock

L Ratiani 1 , N Gvajaia 1 , G Janigashvili 2 , L Gabunia 2

1 The First University Clinic of Tbilisi State Medical University, Department of Anesthesiology and Reanimatology, Tbilisi, Georgia, 2 The First University Clinic of Tbilisi State Medical University, Department of Clinical Pharmacology, Tbilisi, Georgia

Critical Care 2026, 30 (Suppl 1): P269

Introduction: This study evaluated whether interleukin-6 (IL-6) and soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) provide superior prognostic information compared with lactate, C-reactive protein (CRP), and leukocyte count in adults with sepsis or septic shock.

Methods: A prospective cohort of 60 adults admitted with sepsis or septic shock to the First University Clinic, Tbilisi (October 2022–August 2023), was studied. Blood samples were taken on admission and days 1, 2, 3, and 5. IL-6, sTREM-1, and CRP were assessed by electrochemiluminescence; lactate and leukocytes by routine assays. Group differences were analysed using the Kruskal–Wallis test.

Results: Mortality was 76% in septic shock and 38% in sepsis (χ2 = 4.43, p = 0.035) (Figure). Non-survivors had persistently elevated lactate, while survivors showed declines. Baseline lactate and leukocyte count differentiated selected groups (e.g., shock deaths vs shock survivors: lactate p = 0.002; leukocytes p = 0.006), whereas CRP showed no discriminatory value. IL-6 and sTREM-1 levels were higher in non-survivors and decreased in survivors. Within septic shock, both biomarkers distinguished survivors from non-survivors (sTREM-1: H = 8.464, p = 0.003; IL-6: H = 5.377, p = 0.020). sTREM-1 also separated shock deaths from sepsis with recovery (H = 11.097, p = 0.001).

Conclusions: Serial IL-6 and sTREM-1 outperform CRP and leukocyte count and complement lactate for early risk stratification in sepsis, particularly in septic shock. Their integration into routine assessment may improve identification of high-risk patients and guide timely management.

Figure (abstract P269) Longitudinal sTREM-1 concentrations across outcome and severity groups. Median values with interquartile ranges (boxes) and 5–95% distribution (whiskers) are shown for patients with sepsis and septic shock at admission (T = 0) and on days 1, 3, and 5

P270 A novel molecular phenotype based on longitudinal changes in serum Il-6 levels in acute inflammatory diseases

H Matsumoto, Y Mitsuyama, T Ebihara, J Oda

The Department of Traumatology and Acute Critical Medicine, The University of Osaka, Suita, Japan

Critical Care 2026, 30 (Suppl 1): P270

Introduction: Interleukin-6 (IL-6) is a central cytokine that orchestrates systemic inflammatory responses and immune–metabolic networks during acute inflammation. However, in critical care, no cross-disease molecular phenotyping approach has been established based on temporal changes in serum IL-6 levels. Although IL-6 contributes to endothelial injury, hypercoagulability, multiorgan failure, and mortality, phenotypes that capture its longitudinal behavior remain poorly characterized. The aim of study is to define novel phenotypes based on longitudinal changes in serum IL-6 levels and to clarify their association with clinical characteristics and patient outcomes.

Methods: This prospective observational study enrolled patients with acute inflammatory conditions transported to the Osaka University Critical Care Center. Eligible conditions included burns, heat stroke, trauma, intoxication, cardiac and neurological emergencies, infections, and post-resuscitation encephalopathy. Serum IL-6 levels were measured on Day 1 and on Days 3–8 after ICU admission. For each patient, the slope of IL-6 change over time was calculated and categorized as decreasing (Class 1, slope < 0) or non-decreasing (Class 2, slope ≥ 0). Survival was analyzed using the Kaplan–Meier method.

Results: Across all acute inflammatory etiologies, serum IL-6 levels were markedly elevated, and patients were stratified based on temporal IL-6 dynamics. Class 1 included a higher proportion of infectious cases and more frequent use of mechanical ventilation. Class 2 patients were younger than those in Class 1. Kaplan–Meier analysis demonstrated a trend toward poorer survival in Class 2, despite relatively lower initial IL-6 levels, suggesting the presence of a persistent inflammatory state that cannot be explained by baseline IL-6 levels alone.

Conclusions: Phenotyping based on longitudinal changes in serum IL-6 levels identified novel molecular clusters shared across diverse acute inflammatory diseases.

P271 Viscoelastic coagulation monitor as a point-of-care test for early sepsis detection

P Soulioti 1 , AE Rekoumi 1 , G Damoraki 1 , K Leventogiannis 1 , E Polyzogopoulou 2 , J Parissis 2 , EJ Giamarellos-Bourboulis 1

1 National and Kapodistrian University of Athens, 4 th Department of Internal Medicine, Athens, Greece, 2 National and Kapodistrian University of Athens, Emergency Department, Athens, Greece

Critical Care 2026, 30 (Suppl 1): P271

Introduction: Sepsis is often associated with clinical or subclinical coagulopathy. Viscoelastic Coagulation Monitoring (VCM) captures 8 coagulation variables in one hour and it is studied as a point-of-care (POC) tool of early sepsis detection in the emergency department (ED).

Methods: 147 adults admitted at the ED with suspicion of infection were prospectively enrolled. A blood draw via peripheral venipuncture was obtained upon admission and on three consecutive days for patients remaining hospitalized; coagulation tests and inflammatory mediators were measured. Sepsis classification was done by Sepsis-3.

Results: Clotting time was significantly ( p : 0.007) lower in sepsis (median: 322.0, 95% CI: 252.0–391.5) versus non-sepsis patients (Median: 370.5, 95% CI: 296.50–426.2; p : 0.007). The area under the curve of ROC for sepsis diagnosis was 0.649. One cut-off of CT less than 290 s was identified for sepsis diagnosis (negative predictive value 79.2%). In the multivariate analysis, CT was an independent variable of sepsis (Table). Out of range VCM measurements accumulated over time for both groups of comparison, indicating persistence and progression over time.

Conclusions: VCM can be a one POC tool for sepsis detection at the ED.

Table (abstract P271) Multivariate analysis for the early diagnosis of sepsis

P272 Multiclass classification of sepsis using subtype ensembles

LN Ward 1 , J Kennedy 1 , CCH Chang 2 , DC Angus 1 , L Tang 2 , CW Seymour 1

1 University of Pittsburgh, Department of Critical Care Medicine, Pittsburgh, USA, 2 University of Pittsburgh, Department of Biostatistics, Pittsburgh, USA

Critical Care 2026, 30 (Suppl 1): P272

Introduction: Multiple approaches identify sepsis subtypes, yet they may not agree and have significant overlap. Rather than choosing a single approach, multiclass classification creates ensembles of subtypes, yet little is known about their epidemiology and outcomes.

Methods: We performed a secondary analysis of a multicenter prospective cohort study of critically ill adults with sepsis in the MARS cohort, identified with Sepsis-2 or Sepsis-3 criteria upon ICU admission [1]. Clinical, biomarker, and transcriptomic data were used to assign each patient to four subtyping approaches – SENECA, MARS, ARDS subphenotypes, and SRS [1–4]. A portion of patients were further labeled by Dysregulated Immune Profile (DIP) [5]. Ensembles (n = 64) were created using membership from four labels, illustrated with heatmaps, and compared across 28-day in-hospital mortality.

Results: Among 522 patients, the mean age was 61 ± 15 years, 57% were men, and mean SOFA score was 7.3 ± 3.96. There were 42 ensembles identified out of 64 possible. The 4 ensembles with the most patients were γ-Mars3-Hypoinflammatory-SRS2 (12%), γ-Mars2-Hyperinflammatory-SRS1 (9.2%), δ-Mars2-Hyperinflammatory-SRS1 (6.3%), and γ-Mars1-Hypoinflammatory-SRS2 (5.8%). Among these 4 ensembles, there were significant differences in SOFA and APACHE scores and presence of septic shock. Of ensembles with 10 or more patients, the range of 28-day mortality was 0 to 52%, with the δ-Mars1-Hyperinflammatory-SRS1 ensemble the greatest (52% (95% CI: 31%, 73%)) (Figure).

Conclusions: In a prospective cohort study, patients can be feasibly grouped into sepsis subtype ensembles with clinical, biomarker, and transcriptomic data, suggesting potential for further study of mechanistic targets and ensemble-level treatment effects.

References Scicluna BP et al. Lancet Respir Med 2017;5:816–26 Seymour CW et al. JAMA 2019;321:2003–17 Calfee CS et al. Lancet Respir Med 2014;2:611–20 Davenport EE et al. Lancet Respir Med 2016;4:259–71 Leite GGF et al. Crit Care 2024;28:88

Figure (abstract P272) (A) Caterpillar plot showing 28-day mortality of the 17 ensembles with n ≥ 10 patients. Mortality ranged from 0.0% (95% CI: 0.0%, 31%) to 52% (95% CI: 31%, 73%). (B) Heatmap of patients and subtype memberships. Each row represents an individual patient with columns sorted by the 5 different subtype labels (SENECA, MARS, ARDS subphenotypes, SRS, and DIP)

P273 Protein quantification platforms for use in critical care precision medicine trials: a scoping review

R McMullan on behalf of the Queen’s University Belfast, Critical Care and Respiratory Research Group 1 , MR Smit 2 , V Scaravilli 3 , J Millar 4 , J Kataoka 5 , LM Hays 6 , K Reddy 1

1 Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University Belfast, Northern Ireland, UK, 2 Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Netherlands, 3 Dipartimento di Scienze della Salute, Università degli Studi di Milano Bicocca, Monza, Italy, 4 University of Edinburgh Medical School, Edinburgh, Scotland, UK, 5 Department of Pulmonary and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Japan, 6 University College Dublin Clinical Research Centre, St. Vincent's University Hospital, Dublin, Ireland

Critical Care 2026, 30 (Suppl 1): P273

Introduction: Critical care research is undergoing a paradigm shift with the identification of treatment responsive phenotypes across clinical syndromes such as ARDS and sepsis. Phenotype identification has driven the development of classifiers that use panels of cytokines and endothelial injury markers to allocate patients to precision medicine strata. This scoping review summarises available automated protein quantification devices to support the design of biomarker stratified clinical trials.

Methods: We conducted a scoping review (protocol: 10.17605/OSF.IO/FU546). Searches of MEDLINE, Embase and the Espacenet patent database were conducted to 4 April 2025. We included automated devices that quantitatively measured human blood proteins and excluded proof-of-concept, semi-quantitative, microbiological and animal studies.

Results: We included 612 records describing 163 automated devices from 60 manufacturers (Figure). Among multiplex platforms, ELLA (Bio-Techne, Minneapolis, USA) and Simoa HD-X (Quanterix, Billerica, USA) were most frequently reported, with smaller numbers using AFIAS devices (Boditech Med Inc., Chuncheon, South Korea) and Randox Evidence analysers (Randox Laboratories, Crumlin, Northern Ireland). Cytokines were reported in 52 records, with IL-6 being the most commonly reported (38 records), however endothelial injury markers (e.g. angiopoietin-1, angiopoietin-2, VCAM-1 and ICAM-1) were quantified in only four records.

Conclusions: Many automated platforms already exist that can quantify cytokines required for biologically informed phenotyping in critical care. Leveraging existing multiplex cartridges and prioritising key endothelial injury biomarkers on these platforms could markedly accelerate translation of ARDS and sepsis phenotypes into precision medicine trials.

Figure (abstract P273) PRISMA Extension for Scoping Reviews flow diagram for identification and selection of articles and patents describing automated protein measurement devices

P274 Machine-learning algorithm identifies STREM1 has a key biomarker for outcome prediction in a mixed-ICU population

C de Roquetaillade

APHP, Paris, France

Critical Care 2026, 30 (Suppl 1): P274

Introduction: Prognostic assessment in the intensive care unit (ICU) typically relies on severity scores or single biomarkers. Machine learning (ML) may refine risk stratification by integrating multiple biomarkers and clinical variables. To compare the predictive value of inflammatory biomarkers individually and combined using ML for 90-day mortality. Secondary objective was prediction of major adverse kidney events (MAKE).

Methods: Post-hoc analysis of the FROG-ICU cohort including invasively ventilated or vasopressor-dependent patients. Fourteen plasma biomarkers were measured. ML models included LASSO and Random Forest (RF). Variable importance was assessed by mean decrease in accuracy. External validation used the MARS sepsis cohort.

Results: Among 2,061 FROG-ICU patients, 33.2% died by day-90. ML models combining biomarkers and clinical variables performed well for mortality prediction (AUC 0.73 LASSO; 0.74 RF) and outperformed SAPS II (AUC 0.64). sTREM-1 was the top predictor in variable-importance analyses and performed similarly to ML models when used alone (AUC 0.72). For MAKE, sTREM-1 also showed high performance (AUC 0.78) comparable to ML (AUC 0.80–0.84). Results were confirmed in the external MARS cohort (Figure).

Conclusions: ML analysis identified sTREM-1 as a key prognostic biomarker across heterogeneous ICU populations, predicting both mortality and kidney-related outcomes. These findings support further investigation of TREM-1-targeted therapeutic strategies.

Figure (abstract P274) Receiver-operating characteristic (ROC) curves for predicting day-90 mortality (A) and MAKE in ICU (B) based on a multiparametric approach (LASSO, Random Forest) or sTREM-1 alone and SAPS II

P275 Predictive value of serum sPD-L1 combined with disease severity scores for 28-day mortality in sepsis

C Wang, X Song

Shandong Public Health Clinical Center, Department of Critical Care Medicine, Ji nan, China

Critical Care 2026, 30 (Suppl 1): P275

Introduction: Sepsis is a life-threatening syndrome of organ dysfunction resulting from a dysregulated host immune response to infection. Early identification of high-risk patients is essential to improve outcomes, yet no validated method accurately predicts sepsis prognosis. This study aimed to develop an optimized prognostic model by integrating the immune biomarker soluble programmed death-ligand 1 (sPD-L1) with conventional severity scores.

Methods: A retrospective analysis was conducted in the Department of Critical Care Medicine, Shandong Provincial Hospital, from June 2022 to December 2023. A total of 164 septic patients were enrolled, and their clinical data and serum samples were analyzed. The prognostic value of sPD-L1 alone and in combination with established scoring systems—Acute Physiology and Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA), and Sepsis Severity Score (SSS)—was evaluated using receiver operating characteristic (ROC) analysis to predict 28-day mortality.

Results: Among the traditional scores, SOFA showed the best predictive power for 28-day mortality (AUC = 0.799), followed by SSS (AUC = 0.739) and APACHE II (AUC = 0.701) (Table). Serum sPD-L1 also exhibited moderate prognostic value (AUC = 0.712; optimal cutoff = 48.99 pg/mL). Incorporating sPD-L1 into each scoring system improved predictive accuracy, with the sPD-L1 + SOFA model performing best (AUC = 0.846; sensitivity = 83.3%; specificity = 73.5%).

Conclusions: sPD-L1 is significantly associated with 28-day mortality in sepsis and serves as an independent prognostic marker. By complementing the SOFA score’s limited ability to capture immune dysfunction, sPD-L1 enhances risk stratification and outcome prediction. The combined sPD-L1 + SOFA model provides a more accurate and immunologically informed approach for early prognosis in septic patients.

Table (abstract P275) This table highlights that integrating immune biomarker sPD-L1 with conventional severity scores markedly improves prognostic accuracy in sepsis. Among all models, the sPD-L1 + SOFA combination achieved the best predictive performance, underscoring the complementary role of immune markers in refining outcome assessment

P276 Evaluation of calprotectin as a proxy biomarker for sepsis immune dysfunction classification and 28-day mortality

A Alevizou 1 , I Alevroudis 2 , Z Aidoni 3 , S Avgeri 4 , I Giagtzoglou 5 , T Agapitou 6 , C Charatsis 7 , R Van Amstel 8 , S Weis 9 , MG Netea 10

1 Hellenic Institute for the Study of Sepsis, Athens, Greece, 2 Ippokrateion Thessaloniki General Hospital, Intensive Care Unit, Thessaloniki, Greece, 3 AHEPA Thessaloniki General Hospital, Department of Anaesthesiology and Intensive Care Medicine, Thessaloniki, Greece, 4 Sotiria Athens General Hospital, Polyvalent Intensive Care Unit, Athens, Greece, 5 Asklipeion Voula General Hospital, Intensive Care Unit, Voula, Greece, 6 Sotiria Athens General Hospital, Intensive Care Unit of Center for Respiratory Failure, Athens, Greece, 7 Theageneio Thessaloniki General Hospital, Intensive Care Unit, Thessaloniki, Greece, 8 Amsterdam Medical University Center, Department of Intensive Care Medicine, Amsterdam, Netherlands, 9 Jena University Hospital, Department of Anesthesiology and Intensive Care, Jena, Germany, 10 Radboud University Medical Center, Department of Internal Medicine and Radboud Center for Infectious Diseases, Nijmegen, Netherlands

Critical Care 2026, 30 (Suppl 1): P276

Introduction: The ImmunoSep trial ( NCT04990232 ) classified Sepsis-3 patients using blood ferritin and expression of HLA-DR on monocytes. Ferritin > 4,420 ng/mL classified macrophage activation-like syndrome (MALS); the combination of ferritin ≤ 4,420 ng/mL and HLA-DR < 5,000 sepsis-induced immunoparalysis (SII); and the remaining patients were labeled as unclassified for immune state [1]. Calprotectin, predominantly produced by neutrophils and monocytes, contributes to both pro-inflammatory responses and progression toward SII. The added value in outcome prediction was studied.

Methods: In this exploratory post-hoc analysis, plasma calprotectin (S100A8/A9) was measured in 559 of 672 screened patients, using the GCAL® Calprotectin Reagent Kit. Enrolled patients received treatment with precision immunotherapy (anakinra or recombinant human IFN-gamma) or placebo for 15 days. The primary endpoint was the improvement of organ function by day 9 using the SOFA score; 28-day mortality was a secondary endpoint.

Results: Among these 559 patients, 40 were classified as MALS, 230 as SII and 289 were unclassified. Median calprotectin was 7.37, 6.20 and 5.03 mg/l respectively ( p = 0.016 MALS vs unclassified; and p = 0.002 SSI vs unclassified). The Youden index of one receiver operator characteristics curve analysis to discriminate between MALS/SSI and unclassified was 7.75 mg/l. Among patients randomized to treatment, 94 had calprotectin ≥ 7.75 mg/L. In this population, precision immunotherapy provided better odds for survival (Figure).

Conclusions: Findings from the ImmunoSep randomized controlled trial suggest that calprotectin may further select patients with MALS or SII who are most likely to benefit from immunotherapy in terms of survival.

Reference Kotsaki A et al. BMJ Open 2022;12:e067251

Figure (abstract P276) Survival analysis for patients with calprotectin ≥ 7.75 mg/L. Abbreviations: CI, confidence interval; n, number of patients; HR, hazard ratio; SoC, standard-of-care

P277 The effect of statin on sepsis mortality: a systematic review and meta-analysis

T Wang, JT Bao, X Zhou, MF Wu, Y Yang, F Peng

Zhongda Hospital, School of Medicine, Southeast University, Department of Critical Care Medicine, Nanjing, China

Critical Care 2026, 30 (Suppl 1): P277

Introduction: Sepsis remains a major global health problem with high mortality and limited effective adjunctive therapies [1]. Statins have anti-inflammatory, immunomodulatory, and endothelial-stabilizing effects that may provide benefit, but previous randomized clinical trials (RCTs) show inconsistent results. We performed a systematic review and meta-analysis to evaluate the association between statin therapy and mortality in critically ill patients with sepsis.

Methods: Following PRISMA guidelines, we searched PubMed, Embase, Web of Science, and the Cochrane Library through October 14, 2025. RCTs comparing statins with placebo in adult sepsis patients and reporting mortality outcomes were included. Risk ratios (RRs) with 95% CIs were pooled using inverse variance–weighted models. Trial Sequential Analysis (TSA) assessed robustness and evidence sufficiency. Prespecified subgroup analyses were conducted by statin type and enrollment source.

Results: Ten RCTs (n = 1063) were included (Figure). Six trials (n = 613) reported short-term mortality, with statins significantly reducing risk (RR 0.73; 95% CI 0.57–0.92; I2 = 3%). TSA supported this as a reliable finding. Four trials (n = 557) reported long-term mortality, which also favored statins (RR 0.77; 95% CI 0.61–0.90; I2 = 0%), but TSA indicated insufficient cumulative evidence. Subgroup analysis suggested statin-specific effects, with simvastatin showing a stronger mortality reduction than atorvastatin.

Conclusions: Statin therapy was associated with a modest and TSA-supported reduction in short-term mortality in sepsis, whereas evidence for long-term benefit remains inconclusive. Given limited sample sizes and trial variability, these findings should be interpreted cautiously. Larger, high-quality RCTs are needed before statins can be recommended as routine adjunctive therapy for sepsis.

Reference Singer M et al. JAMA 2016;315:801

Figure (abstract P277) Summary of evidence for statin therapy in sepsis (A) PRISMA flow diagram of study selection. (B) Pooled long-term mortality analysis. (C) Pooled short-term mortality analysis. (D) Trial Sequential Analysis (TSA) of short-term mortality

P278 Xuebijing injection ameliorates cytokine storm by regulating monocyte function via the ACTN4/STAT1 pathway in sepsis

D Hu 1 , Y Zhu 1 , L Liu 1 , S Chen 1 , H Xue 1 , Y Wang 2 , S Liu 1

1 Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China, 2 The First People´s Hospital of Lianyungang, Lianyungang, China

Critical Care 2026, 30 (Suppl 1): P278

Introduction: Excessive production triggers a cytokine storm, leading to tissue injury, multiple organ dysfunction, and poor clinical outcomes in sepsis patients. Monocytes play a pivotal role in host defense by secreting a diverse array of cytokines that initiate and regulate inflammatory processes. Previous studies demonstrated that Xuebijing injection (XBJ) reduced 28-day mortality compared with placebo and exerts therapeutic effects on by regulating interferon (IFN) signaling in monocytes. Nevertheless, its specific molecular targets and underlying mechanisms remain unknow.

Methods: THP-1 cells were stimulated with LPS to establish an inflammatory model. Four groups were designed: PBS + Veh (vehicle), PBS + XBJ, LPS + Veh, and LPS + XBJ. IFNs, interferon-stimulated genes (ISGs) and inflammatory cytokines were quantified via RT-qPCR and ELISA. Drug affinity responsive target stability (DARTS) identified direct protein targets of XBJ. AlphaFold 3 predicted the target protein structure, followed by virtual screening and molecular docking to pinpoint key bioactive components. WB and Co-IP validated target expression and pathway interactions.

Results: Compared with the PBS + Veh, the LPS + Veh displayed remarkably upregulated expression of IFNs, ISGs and pro-inflammatory cytokines, while XBJ treatment in the LPS + XBJ markedly reversed these upregulatory effects. DARTS analysis identified α-actinin-4 (ACTN4) as a direct target of XBJ. Molecular docking results revealed strong binding affinities between ACTN4 and two key components: Miltionone II and stigmasterol. WB assays demonstrated that LPS stimulation downregulated ACTN4 expression and upregulated STAT1 expression, whereas XBJ treatment reversed these LPS-induced changes. Additionally, Co-IP assays confirmed the interaction between STAT1 and ACTN4 proteins.

Conclusions: XBJ mitigates sepsis-associated cytokine storm by modulating the ACTN4/STAT1 pathway in monocytes. ACTN4 may be a direct target, with miltionone II and stigmasterol as potential key active constituents.

P279 Heterogeneous treatment effect of xuebijing injection on 28-day mortality in mechanically ventilated patients

S Chen 1 , L Liu 1 , H Xue 1 , D Hu 1 , Y Zhu 1 , Y Yang 1 , H Qiu 1 , S Liu 2

1 Zhongda Hospital, School of Medicine, Southeast University, Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Trauma Center,, Nanjing, China, 2 Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China

Critical Care 2026, 30 (Suppl 1): P279

Introduction: Sepsis remains a leading cause of critical illness and death in intensive care units (ICU), particularly among patients requiring mechanical ventilation (MV). Xuebijing (XBJ) injection, a botanical formulation, has shown survival benefits in sepsis, but its heterogeneous treatment effects (HTE) in MV patients remains unclear.

Methods: A post hoc secondary analysis of multi-center EXIT-SEP randomized controlled trial was conducted, which enrolled adults with sepsis from 45 ICUs in [removed], involving 946 MV patients (463 XBJ, 483 placebo). HTE was assessed through subgroup analysis, causal forest and Bayesian regression to identify patient characteristics predictive of treatment benefit.

Results: XBJ significantly reduced 28-day mortality (26.1% vs. 32.9%; HR: 0.79, 95%CI: 0.65–0.96; p = 0.02), with the greatest benefit observed in males, non-smokers, and patients normal BMI. Causal forest modeling revealed considerable variability in treatment effects, with the highest benefit observed in patients with lower lactate, higher PaO 2 /FiO 2 ratios, and preserved organ function. Patients in the highest benefit tertile (Q3) had markedly lower mortality with XBJ (1.5% vs. 9.0%; ARR: 7.5%, p = 0.04), while the lowest tertile (Q1) showed no benefit ( p = 0.15).

Conclusions: XBJ reduced 28-day mortality in MV patients with sepsis, but treatment effects varied considerably across subgroups. Precision approaches may help identify patients most likely to benefit, supporting individualized sepsis management in the ICU.

P280 Heterogeneous treatment effects of xuebijing injection in patients with sepsis-induced coagulopathy

XR Lou, N Shi, RX Yu, H Chen, Y Yang, YZ Huang, SQ Liu, JF Xie, XJ Wu, HB Qiu

Zhongda Hospital, School of Medicine, Southeast University, Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Nanjing, China

Critical Care 2026, 30 (Suppl 1): P280

Introduction: Patients with sepsis-induced coagulopathy (SIC) have a high mortality risk. Although randomized trials suggest that xuebijing injection (XBJ) can improve outcomes in sepsis, it is unclear whether SIC patients derive similar benefit. This study aims to determine the efficacy of XBJ in patients with SIC and to evaluate how the treatment effect is modified by heterogeneity of treatment effects (HTE) across individuals.

Methods: This exploratory analysis of the EXIT-SEP trial compared XBJ with placebo in sepsis patients from 45 intensive care units across China, enrolled between October 2017 and June 2019. A total of 546 patients who met the SIC diagnostic criteria were included. The primary outcome was 28 mortality. HTE was evaluated using conventional subgroup analysis, risk-based analysis, and effect-based analysis.

Results: A total of 546 patients were included (279 in the placebo group and 267 in the XBJ group), and baseline demographic characteristics were similar between the two groups. There was no statistically significant difference in 28-day mortality between the groups (placebo: 29.7%, XBJ: 22.8%; P = 0.083). Conventional subgroup analyses suggested that the effect of XBJ on mortality differed according to septic shock status (yes vs. no; posterior probability of a difference in OR: 97.8%) and SIC score (4–5 vs. 6; posterior probability of a difference in OR: 99.3%). In the risk-based analysis, patients at the lowest risk of death were most likely to benefit from XBJ (posterior probability of OR < 1: 99.4%) (Figure). In the effect-based analysis, patients with younger age, better coagulation function, and lower proportions of shock and mechanical ventilation at baseline were more likely to benefit from XBJ treatment.

Conclusions: In patients with SIC, the effect of XBJ appeared heterogeneous, with greater benefit among those who were less severely ill at baseline. These findings highlight the importance of accounting for HTE when designing and analyzing randomized controlled trials in SIC.

Figure (abstract P280) Heterogeneity of treatment effect of XBJ on 28-day mortality

P281 Dexamethasone reprograms immune signatures in severe COVID-19: a multi-algorithm feature-selection analysis

C Grimm 1 , L Saager 1 , K Meissner 1 , S Pöhlmann 2 , A Eichmann 3 , O Moerer 1 , M Osuchowksi 3 , T Skirecki 4 , B Scicluna 5 , M Winkler 1

1 University Medical Center Göttingen, Department of Anesthesiology and Intensive Care Medicine, Göttingen, Germany, 2 Infection Biology Unit, German Primate Center – Leibniz Institute for Primate Research, Göttingen, Germany, 3 Ludwig Boltzmann Institute for Traumatology The Research Center in Cooperation with AUVA, Vienna, Austria, 4 Laboratory of Flow Cytometry, Centre of Postgraduate Medical Education, Warsaw, Poland, 5 Department of Applied Biomedical Science, Faculty of Health Sciences, Mater Dei Hospital, University of Malta, Msida, Malta

Critical Care 2026, 30 (Suppl 1): P281

Introduction: Despite its proven survival benefit [1], how dexamethasone (DEX) modulates peripheral immunity in severe COVID-19 remains insufficiently understood.

Methods: We conducted an observational ICU cohort study at the University Medical Centre Göttingen(03/2020–03/2021; ethics #24/4/19Ü) including 45 adults with severe COVID-19 (DEX n = 18; no DEXn = 27). Evolving guidelines enabled comparison of patients receiving DEX (6 mg/day, ≤ 10 days) with earlier untreated patients. Serial blood and PBMC samples underwent broad immune profiling covering T-cell activation/adhesion/exhaustion markers, B-cell naïve/memory subsets, plasmablasts, and monocyte subsets (CD163, CD38, HLA-DR, GILZ). Endothelial/coagulation-related extracellular vesicles and cytokines/soluble proteins were quantified. Five feature-selection algorithms (random forest, LASSO, sPLS-DA, logistic regression, Boruta) identified treatment-associated markers; variables selected by ≥ 3 methods defined consensus features. UMAP was used for visualization.

Results: Eight immune parameters consistently distinguished DEX-treated from untreated patients (Figure). Non-classical monocytes showed increased CD163 and reduced HLA-DR; intermediate monocytes were decreased. T-cell activation/adhesion markers (LFA-1 on CD4⁺, CD49d on CD8⁺) and CD3⁺ T-cell proportions were lower under DEX. CD24⁺ IgD⁻IgM⁻ B cells were expanded. Tissue-factor–positive CMG⁺ endothelial/coagulation events were markedly reduced. UMAP embedding showed clear separation of treatment groups.

Conclusions: Multi-algorithm feature selection revealed a distinct DEX-associated immune signature insevere COVID-19, characterized by anti-inflammatory monocyte polarization, reduced T-cell activation, expansion of CD24⁺ IgD⁻ IgM⁻ B cells, and dampened endothelial/coagulation activity. These findings provide mechanistic insight into corticosteroid responsiveness and may inform immune-guided treatment strategies.

Reference RECOVERY Collaborative Group. N Engl J Med 2021;384:693–704

Figure (abstract P281) Consensus features associated with DEX treatment identified by a multi-algorithm selection approach. (A) Two-dimensional Uniform Manifold Approximation and Projection (UMAP) embedding illustrating the overall feature structure. (B) Distribution of each consensus feature shown using individual violin plots

P282 Trimodulin (polyvalent IgM, IgA, IgG solution) modulates Th17 cell populations

C Baumann, M Visser, F Bohländer

Biotest AG, Dreieich, Germany

Critical Care 2026, 30 (Suppl 1): P282

Introduction: CD4⁺ T helper 17 (Th17) cells are critical mediators of host defense and inflammation. Their dysregulation and excessive IL-17A secretion have been linked to the pathogenesis observed in sepsis and severe community-acquired pneumonia (sCAP). Targeted modulation of Th17 cells therefore represents a promising therapeutic approach. The present study investigated the immunomodulatory effects of trimodulin a polyvalent immunoglobulin preparation comprising ~ 23% IgM, ~ 21% IgA and ~ 56% IgG (Biotest AG) on Th17 cells in vitro.

Methods: Naïve CD4⁺ T cells were isolated from healthy donor blood, differentiated into Th17 cells (co-stimulation with anti-CD3/CD28 and cytokines TGF-β1/IL-6), and treated with trimodulin at concentrations of 1 g/L or 7.5 g/L for four days. Th17 differentiation and proliferation were assessed by flow cytometry using lineage-specific surface markers (CD4, CD25 and CD196) and the transcription factor RORγt. Cytokine concentrations (TNF, IL-2, IFN-γ, IL-10, IL-6, IL-4, TGF-β and IL-17A) were quantified in culture supernatants using a cytometric bead array and ELISA.

Results: High-dose trimodulin (7.5 g/L) treatment led to a significant reduction in Th17 cell frequency and proliferation compared with untreated controls. Cytokine analysis confirmed a marked decrease in secretion of pro-inflammatory mediators (TNF, IL-2, IFN-γ) as well as IL-10. While the formulation buffer displayed some dose-dependent inhibitory effects, trimodulin exhibited an additional suppressive effect on Th17 cells beyond the buffer control.

Conclusions: These data demonstrate that the IgM, IgA, IgG solution trimodulin effectively attenuates Th17 cell differentiation, proliferation, and cytokine secretion in vitro (Figure). The findings suggest that trimodulin may contribute to restoring immune balance in hyperinflammatory conditions and support its potential as an immunomodulatory therapy for severe inflammatory diseases.

Figure (abstract P282) Naïve CD4⁺ T cells were differentiated into Th17 cells and treated with trimodulin (1 g/L or 7.5 g/L). High-dose treatment significantly reduced Th17 cell frequency, proliferation, and secretion of pro-inflammatory cytokines (TNF, IL-2, IFN-γ), as well as IL-10. Trimodulin showed stronger suppression than the buffer control

P283 Trimodulin in severe community-acquired pneumonia: design and statistical concept of the randomized phase III ESsCAPE trial

R Ferrer 1 , C De la Fuente Martos 2 , V Šrámek 3 , V Fraipont 4 , SM Lobo 5 , P Biston 6 , D Wyncoll 7 , A Frenkel 8 , C Schmidt 9 , CC Heinz 9

1 Intensive Care Department, Vall d’Hebron Hospital Universitari. SODIR Research Group, Vall d’Hebron Institut de Recerca VHIR. Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain, 2 University Hospital Reina Sofia, Cordoba Investigation Medical Institute IMIBIC, Spanish Ciberinfect Group, Córdoba, Spain, 3 Department Anesthesia and Intensive Care, St. Anne´s University Hospital, Brno, Czech Republic, 4 Intensive Care Unit, Citadelle Hospital, Liège, Belgium, 5 Intensive Care Division, Hospital de Base and FAMERP, São José do Rio Preto, Brazil, 6 CHU CharleroiChimay, Charleroi, Belgium, 7 Dept of Critical Care, Guy´s St Thomas´ NHS Trust, London, UK, 8 General Intensive Care Unit, Soroka University Medical Center, and The Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel, 9 Corporate Clinical Research Development, Clinical Strategy Development, Biotest AG, Dreieich, Germany

Critical Care 2026, 30 (Suppl 1): P283

Introduction: Severe community-acquired pneumonia (sCAP) remains a life-threatening condition associated with high mortality. Trimodulin is a polyvalent immunoglobulin preparation enriched with IgM and IgA in addition to IgG, supporting a wide array of anti-pathogen and immune modulating activities in the host. In the phase II CIGMA trial, trimodulin significantly reduced mortality in a subset of patients with sCAP on invasive mechanical ventilation (IMV) and with inflammation.

Methods: The ESsCAPE trial is a confirmatory, prospective, randomized (1:1), placebo-controlled, double-blind, multi-center, multi-national, phase III trial evaluating the efficacy and safety of trimodulin as adjunctive treatment to standard of care in patients with sCAP requiring IMV. Eligible patients have a C-reactive protein level of ≥ 70 mg/L. Early after starting IMV (< 24 h), patients receive daily infusions of 3.8 mL/kg/day for five consecutive days. Follow-up assessments are conducted until day 29 and on day 91 to evaluate short- and long-term outcomes (Figure). The primary efficacy endpoint is the 28-day all-cause mortality rate, evaluated in a predefined IgM-low subset of patients (IgM ≤ 0.8 g/L at baseline), as well as in the overall population. A flexible-adaptive design will be applied: Approximately 590 patients are expected to be required to demonstrate superiority of trimodulin over placebo. An interim analysis is planned after enrolling about 50% of patients to guide potential sample size adaptation. Further secondary endpoints address safety, the pharmacokinetics of trimodulin, and pharmacodynamic responses modulated by trimodulin. Analyses will be conducted on an intention-to-treat basis.

Results: Currently, the trial is actively enrolling patients.

Conclusions: Trimodulin may offer clinical benefit in critically ill patients with sCAP and systemic inflammation. The confirmatory ESsCAPE trial is expected to provide valuable data on its efficacy and safety in this patient population.

Figure (abstract P283) Overview of trial design

P284 Immunomodulatory therapy is associated with improved organ function in sepsis: a systematic review and meta-analysis

J Hollosi, C Turan, A Walter, P Bakos, L Zubek, C Alkan, K Koch, Z Molnar, P Hegyi

Semmelweis University, Centre for Translational Medicine, Budapest, Hungary

Critical Care 2026, 30 (Suppl 1): P284

Introduction: Sepsis remains a leading cause of mortality in ICUs, hence adjunctive immunomodulatory therapies such as intravenous immunoglobulin (IVIG), plasmapheresis, hemadsorption, or polymyxin B adsorption have been proposed, but their effects remain uncertain. We compared these therapies in sepsis with a network meta-analysis.

Methods: We systematically searched 3 major databases on October 30, 2024. Only randomized controlled trials (RCTs) of adult septic patients receiving immunomodulatory therapies reporting changes in organ dysfunction scores and mortality rates were included. Comparisons were performed using a frequentist network meta-analysis approach, applying a random effects model to account for the considerable between-study heterogeneity observed among the included studies. All analyses were conducted using the netmeta (v2.9–0) and dmetar (v0.1.0) packages in R (v4.4.2). Results were visualized via forest plot and surface under the cumulative ranking curve (SUCRA) plots.

Results: 70 RCTs met criteria. Polymyxin B showed significant improvement in SOFA score compared to standard therapy (mean difference -2.06 points, 95% CI: -3.17 to -0.90), while other therapies showed a tendency towards a lower score without reaching statistical significance. In addition, plasmapheresis showed a significant odds ratio of 0.48 (95% CI: 0.28 to 0.83) in 28-day mortality, while other therapies showed a tendency toward improved mortality odds as well (Figure).

Conclusions: Adjunctive immunomodulatory therapies may improve sepsis outcomes. Further trials are needed to clarify optimal patient selection and treatment strategies, but clinicians may consider these therapies alongside standard care.

Figure (abstract P284) Change in SOFA score SUCRA plot

P285 Do hemoperfusion systems deliver what they claim? An in vitro evaluation targeting inflammatory mediators

S Harm, C Schildböck, J Hartmann

University for Continuing Education Krems, Department for Biomedical Research, Krems, Austria

Critical Care 2026, 30 (Suppl 1): P285

Introduction: Systemic inflammation and endotoxemia drive organ dysfunction in critical illness. Hemoperfusion devices are used to reduce circulating inflammatory mediators. We hypothesized that commonly used adsorbers differ markedly in their ability to remove inflammatory cytokines and endotoxin from human whole blood.

Methods: Three adsorbers with different marketed claims were tested: CytoSorb300 (cytokine removal; LOT 111424B) and Jafron HA380 (cytokine removal; LOT 2402280101) and Efferon LPS (cytokine + endotoxin removal; LOT 25-LEU001). Fresh heparinized whole blood was spiked with LPS (10 EU/mL) and incubated for 6 h at 37 °C to induce inflammation; IL-10 and PCT were added exogenously. Batch experiments (n = 6) ran for 2 h with an adsorber-to-blood ratio of 1:10, dynamic experiments for 6 h in a miniaturized extracorporeal circuit. Pre- and post-treatment levels of IL-6, IL-1β, IL-10, IL-18, TNF-α, PCT and LPS were measured using multiplex ELISA and an adapted limulus amebocyte lysate assay [1].

Results: None of the devices removed endotoxin. All systems reduced PCT. CytoSorb300 achieved the strongest cytokine reduction across IL-6, IL-10, TNF-α, IL-18 and IL-1β (Figure). Jafron HA380 showed only modest cytokine decreases. In contrast, the Efferon LPS adsorber, despite being marketed for LPS and cytokine removal, caused a marked increase in IL-1β and IL-18 in both models – indicative of NLRP3 inflammasome activation – and failed to remove endotoxin.

Conclusions: In our in-vitro whole blood setup, CytoSorb300 showed the most effective reduction of inflammatory mediators, Jafron HA380 demonstrated limited efficacy, and the Efferon LPS cartridge removed neither cytokines nor endotoxin while increasing inflammasome-related cytokines. These findings reveal substantial performance differences between hemoperfusion systems and support the need for rigorous preclinical testing prior to clinical application.

Acknowledgement: This study was funded by the government of lower Austria with the project ID #WST3-F-5030664/030-2022 (biomimetic surfaces) and Cytosorbents Europe GmbH.

Reference Harm S et al. Sci Rep 2024;14:2410

Figure (abstract P285) Blood levels of IL-1β, TNF-α, IL-6 and endotoxin activity after 6-h hemoperfusion in the dynamic extracorporeal circuit

P286 Effect of acute blood purification using a novel blood purification column in critically ill ICU patients: a single-center retrospective study—the REMCYTO study

T Horiuchi, K Sato, T Taniguchi

Kanazawa University, Department of Anesthesiology and Intensive Care Medicine, Kanazawa, Japan

Critical Care 2026, 30 (Suppl 1): P286

Introduction: Critically ill patients in the intensive care unit (ICU) often require continuous kidney replacement therapy (CKRT). The blood purification column Remcyto™ developed by our group in 2023 showed favorable cytokine adsorption and biocompatibility in vitro [1]. This study aimed to evaluate its clinical utility.

Methods: We retrospectively included adult ICU patients between February 2024 and October 2025 who underwent CKRT for acute kidney injury (AKI) based on the KDIGO classification. Day 0 was defined as the start of CKRT, and data were collected through Day 4. Blood samples were analyzed for blood gas, complete blood count, and biochemistry including IL-6, lactate, and procalcitonin (PCT). SOFA scores and catecholamine index (CAI) were also calculated. The primary endpoints were changes over time in SOFA score, IL-6, lactate, CAI, and PCT from Day 0 to Day 4. The secondary endpoint was ICU length of stay. Continuous variables are presented as median (interquartile range). Changes over time in primary endpoints were evaluated using a linear mixed-effects model with Day as a fixed effect and patient ID as a random effect.

Results: Seventy patients (39 males, 31 females; median age 68.5 years) were included. Median ICU stay was 7 days. All primary endpoint measures showed significant decreases from Day 0 to Day 4:SOFA score decreased from 12 (10–16) to 11 (9–14), IL-6 from 1,786 (120–21,802) to 93 (28–227) pg/mL, lactate from 2.0 (1.1–4.2) to 1.3 (0.9–1.6) mmol/L, CAI from 23.3 (4.8–34.1) to 0.9 (0–3.5), and PCT from 21.0 (1.8–60.4) to 6.6 (0.9–20.5) ng/mL (Figure).

Conclusions: In AKI patients treated with CKRT using the novel Remcyto™ column, inflammatory markers and hemodynamic indices improved over time. This device may be useful in the management of critically ill patients, and further validation in comparative and multicenter prospective studies is warranted.

Reference Yamamoto T et al. Blood Purif 2024;53:61–70

Figure (abstract P286) Trajectories of SOFA score, IL-6, lactate, CAI, and PCT from day 0 to day 4. Each variable was log-transformed and evaluated using a linear mixed-effects model (LMM), and the values shown represent back-transformed least-squares means with 95% confidence intervals. Different letters indicate significant differences between days ( p < 0.05)

P287 Detection of Oxiris membrane saturation based on endotoxin and cytokines adsorption kinetics in critically ill septic patients: protocol for the OxiCLEAR (Oxiris cytokines and endotoxin adsorption rate) study

D Smirnova 1 , M Broman 2 , G Villa 3 , O Sabelnikovs 4

1 Paulswe Stradins Clinical University Hospital, Department of Anesthesiology and Reanimatology, Riga, Latvia, 2 Skåne University Hospital Perioperative and Intensive Care, Lund, Sweden, 3 Department of Anesthesia and Intensive Care, Section of Oncological Anesthesia and Intensive Care, Careggi University Hospital, Florence, Italy, 4 Riga Stradins University, Department of Anesthesiology, Intensive Care and Clinical Simulations, Riga, Latvia

Critical Care 2026, 30 (Suppl 1): P287

Introduction: Septic shock involves a dysregulated host response with excessive cytokines release, endotoxin burden, and progressive multi-organ dysfunction. The Oxiris membrane provides combined renal support and adsorptive removal of cytokines and endotoxin; however, the time-dependent decline in adsorptive capacity and optimal timing for membrane exchange remain unclear. We hypothesize that the Oxiris membrane exhibits progressive saturation of binding sites, reducing clearance efficacy. The OxiCLEAR study aims to characterize the adsorption kinetics of endotoxin and cytokines and identify the saturation point of the Oxiris membrane during continuous veno-venous hemofiltration (CVVH) in critically ill septic patients.

Methods: This single-centre prospective observational study will include adult patients with sepsis-associated acute kidney injury requiring standardized CVVH with Oxiris for ≥ 24 h. Endotoxin and cytokines concentrations will be measured in pre-filter, post-filter, and effluent samples at baseline, 1 h, 3 h, 6 h, 12 h, and 24 h using the same membrane set [Figure]. Endotoxins will be quantified by the LSBio Gram-Negative Endotoxin Competitive ELISA and cytokines by the Randox Evidence Investigator Cytokine and Growth Factors Array. Adsorptive efficiency will be calculated from inlet–outlet concentration gradients normalized to plasma flow, while effluent analyses will determine convective clearance. Hemodynamic parameters, organ dysfunction indices, and inflammatory markers will be recorded. Ethical approval: Riga Stradiņš University Ethics Committee (2-PĒK-4/429/2022).

Results: Not applicable.

Conclusions: This study will define the time-based profile of Oxiris adsorption and identify the point of functional saturation, establishing the effective adsorption window. The OxiCLEAR study is expected to provide evidence to optimize the timing of membrane replacement and enable more precise, targeted use of adsorptive renal support therapy in septic shock. Figure (abstract P287) Sampling scheme showing inlet (pre-filter), outlet (post-filter), and effluent sampling sites for evaluating endotoxin and cytokines adsorption at 0 (baseline), 1, 3, 6, 12, and 24 h during CVVH with the Oxiris set

P288 The use of Oxiris in the ICU: a Delphi consensus of recommendations

J Kurz 1 , G Villa 2 , N Van Regenmoertel 3 , M Bell 4 , A Mingoia 5 , F Ramasco 6 , T Rimmelé 7 , D Smirnova 8 , M Broman 9

1 Vantive Health, Medical Director, München, Germany, 2 Department of Health Sciences, University of Florence, Italy; Department of Anesthesia and Intensive Care, Careggi Hospital, Italy, Florence, Italy, 3 University Hospital, Department of Perioperative Medicine and Intensive Care PMI, Karolinska University Hospital, Stockholm, Sweden, 4 Karolinska Institutet, Department of Perioperative Medicine and Intensive Care PMI, Karolinska University Hospital, Stockholm, Sweden, 5 Centre Hospitalier, Critical Care Unit, Centre Hospitalier Wallonie Picardie, Tournai, Belgium, 6 Hospital Universitario de La Princessa, Universidad Autónoma de Madrid UAM, Madrid, Spain, 7 Université de Nice, Department of Anesthesiology and Intensive Care Medicine, Nice University Hospital, Nice, France, 8 University Hospital, Department of Anesthesiology, Intensive Care and Clinical Simulations, Riga Stradiņš University; Department of Anesthesiology and Reanimatology, Pauls Stradiņš Clinical University Hospital, Riga, Latvia, 9 Skane University Hospital, Perioperative and Intensive Care, Lund, Sweden

Critical Care 2026, 30 (Suppl 1): P288

Introduction: The Acute Dialysis Quality Initiative (ADQI) has provided guidance on the management of acute kidney injury (AKI), including extracorporeal blood purification (EBP) techniques [1]. Recent studies have suggested EBP connected to a cardiopulmonary bypass (CPB) circuit results in a significant reduction in cardiac surgery-associated AKI [2]. Oxiris is an EBP device that provides three distinct mechanisms of purification, diffusion, convection and adsorption of cytokines and endotoxins, simultaneously. To provide guidance on the optimal use of Oxiris for critically ill patients, fourteen intensivists convened to reach a consensus on prescription, patient selection and monitoring of Oxiris treatment.

Methods: A consensus meeting was held in Rome on 20th November 2024, chaired by a non-voting clinical moderator with experience in blood purification and critical care. The overall process followed a modified Delphi methodology, which included a literature analysis, an online pre-meeting survey, an in-person consensus meeting, and an online post-meeting survey.

Results: Consensus was reached for multiple statements. Experts agreed that patients who have conditions characterized by dysregulated systemic inflammation and/or endotoxemia may benefit from treatment with Oxiris. There was a majority agreement that several clinical parameters should be evaluated in conjunction to indicate treatment effectiveness. Moreover, experts agreed that hemodynamic improvement is an adequate surrogate for treatment effectiveness.

Conclusions: This consensus process provided practical guidance on patient selection, treatment timing, prescription strategy and monitoring. Consensus was reached on its usefulness in sepsis and other conditions of acute systemic inflammation.

References Bellomo R et al. Nephrol Dial Transplant 2024;39:1945–1964 Pérez-Fernández X et al. JAMA 2024;332:1446–1454

P289 Adjunctive cytokine hemoadsorption in toxic shock syndrome: a case series

A Burov 1 , M Maslennikova 2 , S Vladimirov 2 , A Bryleva 2 , N Matushkov 2

1 Kommunarka Medical Center, Intensive Care, Moscow, Russian Federation, 2 Kommunarka Medical Center, Moscow, Russian Federation

Critical Care 2026, 30 (Suppl 1): P289

Introduction: Toxic shock syndrome (TSS) carries high mortality despite antimicrobials and organ support. As additional therapeutic option for patients who do not respond to standard of care, use of inflammatory mediator adsorption may be considered. We describe our experience with adjunctive hemoadsorption in patients with TSS.

Methods: In this case series, we included seven consecutive ICU patients with TSS requiring ≥ 0.3 µg/kg/min norepinephrine despite standard care: four with necrotizing fasciitis, two with postpartum endometritis, and one with community-acquired pneumonia. In all patients, Streptococcus pyogenes or Streptococcus pneumoniae were identified as the pathogen. Each patient received blood purification approach, which included CRRT with an enhanced-permeability membrane (EMIC2) and an inflammatory mediator adsorber (CytoSorb) for 1–2 sessions. We report baseline characteristics and the evolution of the Vasoactive-Inotropic Score (VIS), serum lactate, interleukin-6 (IL-6), procalcitonin (PCT), and SOFA score over 72 h.

Results: Patients were severely ill at hemoadsorption initiation (median SOFA 16 [IQR 14–18], median norepinephrine 1.2 µg/kg/min [0.95–1.3]). Within 72 h, we observed a reduction in median SOFA score (from 16 to 6), VIS (from 120 to 35), lactate (from 3.4 to 1.2 mmol/L), PCT (from 52.6 to 18.65 ng/mL) and within 48 h- reduction in median IL-6 (from 3450 to 236 pg/mL). Shock was reversed (vasopressor-free for > 24h) in 6/7 patients. Six patients survived to ICU discharge, and one died from refractory multiorgan failure.

Conclusions: In this case series, adjunctive inflammatory mediators hemoadsorption was integrated into CRRT for severe TSS. Clinical improvement, including hemodynamic stabilization and MOF severity reduction, was observed following its application. These preliminary findings support the feasibility of this approach and justify further investigation in controlled trials.

P290 Metaanalysis of extracorporeal cytokine removal therapies in COVID-19

AM Kersten 1 , K Thiele 2 , A Krannich 3 , M Dreher 4 , N Marx 1

1 University Hospital Aachen, Department of Cardiology, Pulmonology, Angiology and Critical Care, Aachen, Germany, 2 University Hospital Aachen, Department of Cardiology, Angiology and Critical Care, Aachen, Germany, 3 BioStats GmbH, Nauen, Germany, 4 University Hospital Aachen, Department of Pneumology and Critical Care, Aachen, Germany

Critical Care 2026, 30 (Suppl 1): P290

Introduction: COVID-19 showed dysregulated host immune response and severe inflammation and endothelial injury. Extracorporeal blood purification techniques (CytoSorb) are adjunctive therapies to mitigate hyperinflammation. Clinical data supporting efficacy are sparse and inconsistent. This meta-analysis sought to evaluate outcomes in controlled and single-arm studies of extracorporeal cytokine removal use in critically ill COVID-19 patients.

Methods: We performed a comprehensive systematic literature search (PubMed, Cytosorbents database) to identify trials reporting mortality in critically ill COVID-19 treated with CytoSorb. We sratified into controlled (comparator arm) and single-arm trials (CT, ST). The longest reported mortality endpoint was analyzed, if it assessed mortality during COVID-19-related critical illness. When mortality timing was not stated, endpoint classification Referenced to the primary data source. Pooled OR for mortality were calculated for CT and were estimated for ST using random-effects models to account for between-study heterogeneity.

Results: We included 11 CT (3 randomized, 1 prospective, 7 retrospective;n = 507 (Figure, panel A). Pooled OR favored CytoSorb (OR 0.74; 95% CI: 0.27–1.98) with a large CI not reaching statistical significance. In 16 ST (n = 368, Figure, panel B) the random effects pooled mortality rate was 38% (95% CI: 0.29 – 0.47). This is lower than comparable reported mortality rates: ECMO 42–53%; CRRT without ECMO 44–53%. Previously reported concerns regarding potential harm by CytoSorb were not substantiated in this more comprehensive synthesis.

Conclusions: CytoSorb was associated with trends to lower mortality compared to benchmark outcomes. No signals of harm were detected. There was a high degree of heterogeneity (significant heterogeneity test and high I 2 ). Use of ECMO and CRRT varied greatly between studies. The results justify continued differentiated evaluation of CytoSorb in severe hyperinflammatory conditions, both within and beyond the context of COVID-19. Figure (abstract P290) Analysis of A) controlled and b) single arm trials

P291 Perioperative hemoperfusion after noncardiac surgery in the general SICU: a preliminary report

S Kongsayreepong, S Laoamornphunkul, N Hemtanon

Siriraj Hospital, Mahidol University, Department of Anesthesiology, Bangkok, Thailand

Critical Care 2026, 30 (Suppl 1): P291

Introduction: Hemoperfusion therapy (HP) has been used for cytokine/endotoxin removal to improve the disturbed immune homeostasis in septic shock and severe ARDS [1]. Less information after noncardiac surgery was reported. This study aimed to evaluate the impact of HP in pts after noncardiac surgery in the general SICU on inflammatory markers, hemodynamic, respiratory, renal parameters and 28-day mortality.

Methods: This retrospective study was done in pts after noncardiac surgeries having HP in the SICU between Jan 2015-April 2024 (excluding trauma, neurological, cardiothoracic surgeries). Study data included: demographic, ASA, comorbidities, type of surgeries, site & severity of infection, organ injury, any CRRT/ECMO support, APACHE-II score, indication for HP, inflammatory biomarker (IL-6, CRP, PCT, WBC, serum lactate, SOFA scores before and after HP, 28-day mortality.

Results: Among 43 pts; age (72.60 + 11.80yrs); BMI (23.12 + 3.77kgs); APACHE-II score (24.23 + 5.09); ASA-III (4.6%), ASA-IV-V(95.4%). Indications for hemoperfusion were septic shock (81.4%) and ARDS (18.6%). All pts underwent HP with HA-330 cartridges® while 4 pts had oXylis cartridges® combined with HA-330 after hemocultures showed gram–ve rod. All inflammatory biomarkers were significantly lower after hemoperfusion (Figure), especially cardiovascular, pulmonary and renal SOFA scores. No bleeding or thrombocytopenia was found. 5 pts had pre-emptive & post-emptive HP before and after drainage of abdominal sepsis with much clinical improvement except 2 pts died from bowel gangrene due to high NE used. 28-day mortality was 51.8% from fungal infection, inadequate source eradication, multiorgan failure from late start HP and bowel gangrene.

Conclusions: Hemoperfusion therapy significantly reduced inflammatory markers & improve SOFA scores. As this is a rescue therapy, it helps protect organs from injury that should be started early. Care should be considered after hemoperfusion eg. eradicating the infection sources to increase the success of this treatment. Figure (abstract P291) Inflammatory biomarkers & SOFA scores (pre & post hemoperfusions)

Reference Li Y et al. Blood Purif 2025;54:122–37

P292 Early physiologic response to Jafron® hemoadsorption in refractory shock: a retrospective ICU cohort

CRC Cerca, MC Costa, I Quinteiro, A Balbino, L Santos, A Azevedo, AF Monteiro, AL Valente, L Bento

Unidade Local de Saúde do Hospital de São José Serviço de Medicina Intensiva Unidade de Urgência Médica, Lisboa, Portugal

Critical Care 2026, 30 (Suppl 1): P292

Introduction: Hemoadsorption is increasingly used as adjunctive therapy in refractory shock to reduce cytokine-driven inflammation. Evidence suggests likely upsides in septic and hemorrhagic shock, mitigating ischemic-reperfusion injury, though clinical outcomes remain inconsistent. This study evaluates physiologic effects, safety, and short-term outcomes following hemoadsorption in critically ill patients.

Methods: We performed a single-center retrospective analysis of 15 ICU patients with refractory shock treated with Jafron® cartridges. Demographics, severity, vasopressor requirements, inflammatory biomarkers (CRP, PCT, IL-6), microbiology, and complications were recorded. Changes in SOFA, norepinephrine (NE) dose, lactate and biomarkers at 24 h were analyzed using paired non-parametric tests. ICU and 28-day mortality were assessed.

Results: Fifteen patients were included; 8 with septic shock, 6 with hemorrhagic shock and 1 with drug intoxication; 67% were male. Severity was high (mean SAPS II 63; mean SOFA 14). All required mechanical ventilation, with a median PaO₂/FiO₂ of 160. At 24 h, the SOFA score decreased from 14 to 12 ( p < 0.01). Median norepinephrine dose fell from 1.2 ± 0.83 mcg/kg/h to 0.4 ± 0.34 mcg/kg/h ( p < 0.01) and lactate declined from 2.5 ± 4.40 mmol/L to 1.7 ± 2.07 mmol/L ( p < 0.01). PCT and IL-6 showed marked reductions, while CRP trended downward. Complications were limited to circuit issues. ICU mortality was 40%, and 28-day mortality 47%, consistent with expected severity. Survivors started hemoadsorption earlier (within 1 day) than non-survivors (within 3 days).

Conclusions: Hemoadsorption was associated with early improvement in organ dysfunction, hemodynamics, and inflammatory burden, with a good safety profile. Although findings support potential immunomodulatory benefit, the small cohort and retrospective design limit conclusions. Larger controlled studies are needed to define optimal timing, patient selection, and clinical impact.

P293 The effects of acute blood purification therapy with a new hemofiltration column in septic shock patients- a retrospective single center study- subanalysis REMCYTO study

T Taniguchi, T Horiuchi, K Sato

Kanazawa University, Anesthesiology and Intensive Care Medicine, Kanazawa, Japan

Critical Care 2026, 30 (Suppl 1): P293

Introduction: Patients with septic shock often undergo acute blood purification (BP) therapy due to acute kidney injury. In 2023, we developed a new BP column (Remcyto™) and demonstrated the effects of this column in vitro and in vivo study [1]. The present study purpose to evaluate whether this therapy in septic shock patients is effective.

Methods: This study was a subanalysis of the REMCYTO study, and all case selection and analysis were redone. Adult patients with septic shock and acute renal failure admitted to our ICU between January 2024 and October 2025 were included. After admission to the ICU, BP using Remcyto™ was performed and continued until renal function recovered. After ICU admission, blood gas analysis and biochemistry were measured over 4 days. The SOFA score and Catecholamine index (CAI) were calculated during the course of the study. Primary endpoints were changes in SOFA score, IL-6, lactate, and CAI over the first 4 days after admission. Secondary endpoints were survival rate, length of ICU stay. Statistics were reported as mean ± SD. Changes over time in primary endpoints were evaluated using a linear mixed-effects model with Day as a fixed effect and patient ID as a random effect.

Results: During the study period, 36 patients (20 men, 16 women, mean age 64.8 years) were enrolled. Three died, and 33 were transferred from the ICU. The median ICU stay was 7.0 days. At ICU admission, SOFA, IL-6, PCT, lactate, and CAI were 13.2, 37,608, 60.1, 3.6, and 32.1, respectively. By day 4, these values significantly decreased to 10.0, 493, 23.5, 1.4, and 3.4, respectively (Figure).

Conclusions: While future multicenter, prospective studies and comparative studies with other BP columns are needed, the present study found that CAI, SOFA, IL-6 and lactate improved during BP. These findings suggest that Remcyto™ is useful for patients with septic shock. Figure (abstract P293) Results

Reference Yamamoto T et al. Blood Purif 2024;53:61–70

P294 Hemoadsorption in critical care: real world outcomes from the international COSMOS registry

R Ferrer 1 , T Kirschning 2 , M Unglaube 3 , N Malewicz Oeck 4 , J Kreutz 5 , M Tholl 6 , B Tyczynski 7 , D Henzler 8 , T Klaus 9 , FS Taccone 10

1 Vall d'Hebron University Hospital, Shock, Organ Dysfunction and Resuscitation Research Group SODIR, Barcelona, Spain, 2 Heart and Diabetes Center NRW, Bad Oeynhausen, Germany, 3 Helios Dr. Horst Schmidt Klinik Wiesbaden, Wiesbaden, Germany, 4 BG University Hospital Bergmannsheil, Bochum, Germany, 5 University Hospital, Philipps University of Marburg, Marburg, Germany, 6 Klinikum Oldenburg AoeR, Oldenburg, Germany, 7 University Clinic Essen, Essen, Germany, 8 Ruhr University Bochum, Hospital Herford, Herford, Germany, 9 CytoSorbents Europe GmbH, Critical Care, Berlin, Germany, 10 Hôpital Universitaire de Bruxelles HUB, Université Libre de Bruxelles ULB, Brussels, Belgium

Critical Care 2026, 30 (Suppl 1): P294

Introduction: COSMOS is a prospective, international registry ( NCT05146336 ) capturing utilization patterns and clinical outcomes with CytoSorb® (CS) use in critical care patients.

Methods: Clinical parameters were assessed 24 h before and after CS therapy with a 90-day follow-up. Investigators reported device-related adverse events. Analyses followed a predefined statistical plan, using descriptive statistics and paired tests. Only patients with complete datasets were included.

Results: This analysis included 306 patients (30% female, mean age 58 ± 17) from 23 sites in 6 countries. Main indications were septic shock (46.9%), cardiogenic shock (13.4%), rhabdomyolysis (12.3%), liver failure (11.4%), and ARDS (6.0%). CS was combined with RRT (90.5%), ECMO (3.9%) or used in hemoperfusion mode (6.2%). The median of baseline APACHE II and Charlson scores were 24 [19, 30] and 4 [2, 5], respectively. Over the course of CS treatment fluid balance, P/F ratio and norepinephrine improved significantly (all p < 0.0001, Figure). Vasopressor index score improved from 20.1 [6.5, 42.4] to 7.6 [2.3, 21.7] and pH went from 7.36 [7.3, 7.42] to 7.41 [7.36, 7.45] (all p < 0.0001). Platelet counts decreased from 127 [76, 197] to 70 [39, 112] × 109/L ( p < 0.0001) and albumin levels from 2.6 [2.3, 3.1] to 2.5 [2.2, 3.0] g/dL ( p = 0.02). In patients without RRT creatinine declined from 2.0 [1.2, 3.2] to 1.3 [0.8, 1.8] mg/dL ( p < 0.0001) and lactate from 2.1 [1.2, 3.3] to 1.4 [1.1, 1.7] mmol/L ( p = 0.02). Overall SOFA score improved from 12 [9, 15] to 11 [8, 14] ( p < 0.0001). ICU mortality was 32.7%, which was lower than predicted by risk scores. At 90 days survival rate was 56.5% with 90.1% being dialysis-free. No serious adverse device effects or device deficiencies were reported.

Conclusions: CS hemoadsorption as adjunct therapy in critical care patients is generally safe and helps achieve important treatment goals including reduction in vasopressors, improved oxygenation and fluid balance. These findings need to be validated in controlled studies. Figure (abstract P294) Changes in fluid balance, oxygenation and norepinephrine in the 24-h periods before versus after CytoSorb® treatment; data are presented as median values with data distribution

P295 Combined double plasma molecular adsorption system (DPMAS) with sequential low-dose plasma exchange (LPE) and high volume plasma exchange (HPV) in acute-on-chronic liver failure: a prospective cohort study

V Xuan Toan 1 , D Ngoc Son 2 , B Van Cuong 2 , D Quoc Tuan 2 , N Cong Tan 2 , B Thi Huong Giang 2 , P The Thach 2

1 Bach Mai Hospital, ICU, HaNoi, Viet Nam, 2 Bach Mai Hospital, HaNoi, Viet Nam

Critical Care 2026, 30 (Suppl 1): P295

Introduction: ACLF causes multiple organ failure and high short-term mortality. DPMAS clears protein-bound toxins, while LPE/HVP replenishes plasma components. Their sequential use may enhance detoxification and improve short-term outcomes. This study compares DPMAS + LPE with HVP in ACLF patients.

Methods: A study at the Center for Critical Care Medicine, Bach Mai Hospital enrolled 54 ACLF patients (DPMAS + LPE: 32; HVP: 22) per APASL 2023 criteria. DPMAS used HA330-II and BS330 cartridges in series, followed by low-dose PEX (1.0–1.5 L). Clinical, biochemical, and inflammatory markers were assessed before and after each session. Primary outcomes were changes in ammonia, total/direct bilirubin; secondary outcomes were 30-day survival and clinical recovery.

Results: End of each session, the DPMAS + LPE group showed significantly greater reductions in total bilirubin (− 139.6 ± 86.2 vs − 88.0 ± 109.5 µmol/L, p < 0.01) and direct bilirubin (− 94.4 ± 66.1 vs − 59.6 ± 79.3 µmol/L, p < 0.01) compared with the HVP group, indicating superior detoxification efficacy (Figure). Ammonia levels decreased modestly in both groups without statistical significance ( p = 0.999). At 30 days, survival rates were 87.5% in the DPMAS + LPE group and 81.8% in the HVP group ( p = 0.564). The overall clinical success rate (complete or partial recovery) was higher in DPMAS + LPE (40.6%) than in HVP (27.3%), though not statistically significant ( p = 0.389).

Conclusions: Combined DPMAS + LPE significantly reduced bilirubin and improved short-term biochemical recovery more than HVP, indicating superior clearance of protein-bound toxins. Its better clinical recovery trend suggests value as a bridge to hepatic regeneration, while similar 30-day survival shows both methods remain viable bridging options before liver transplantation. Figure (abstract P295) The Figure depicts the changes in ammonia, total bilirubin, and direct bilirubin from baseline (T₀) to immediately post-treatment (T₂), comparing the DPMAS + LPE group with the HVP group. A more pronounced reduction across all parameters is observed in patients treated with DPMAS + LPE

P296 From liver transplantation to ischaemic cholangiopathy

M Pinheiro 1 , C Pratas 1 , N Germano 1 , É Mateus 2 , H Pinto Marques 3

1 Unidade Local de Saúde de São José Hospital Curry Cabral, Unidade de Cuidados Intensivos Polivalente, Lisboa, Portugal, 2 Unidade Local de Saúde de São José Hospital Curry Cabral, Unidade de Transplantes, Lisboa, Portugal, 3 Unidade Local de Saúde de São José Hospital Curry Cabral, Serviço de Cirurgia Hepatobiliopancreática, Lisboa, Portugal

Critical Care 2026, 30 (Suppl 1): P296

Introduction: Liver transplantation (LT) is the gold standard treatment for end-stage hepatic failure, with an excellent survival rate lately. However, post-operative biliary complications are a frequent cause for patient morbidity and mortality. Ischaemic cholangiopathy (IC) is characterized by multiple diffuse non-anastomotic strictures affecting the graft biliary system in the absence of hepatic artery thrombosis or stenosis.

Methods: This study aims to explore potential risk factors for the development of IC after LT. We conducted a retrospective analysis of ICU admissions following LT from January 1, 2018, to December 31, 2019. Exclusion criteria were death or re-LT within 30 days after the initial LT. Data were extracted from hospital records, and statistical analysis was performed using SPSS v27.

Results: Of the 231 LTs performed in our center, 197 were included in this study, with 69.5% being men and a mean age of 53,3 years. Nine were excluded due to re-LT, and 25 due to death within 30 days after LT. LTs were mostly due to viral and/or alcoholic cirrhosis, with a mean MELD score of 16.4 and with 26.4% being urgent. Mean donor age was 62,3 years and mean cold ischemia time was 7 h. A total of 17 (8.6%) patients developed IC, 70% of them in the first 6 months. The variables that showed statistical correlation ( p < 0.05) with the development of IC were the following: recipients’ age at the time of the LT, total days in the ICU, the occurrence of hepatic thrombosis, the number of red blood cell transfusions and maximum lactate measurement in the first 24 h post-LT. IC was associated ( p < 0.05) with higher rate of re-LT (64.7% vs 3.9%) and shorter graft survival time (33.4 vs 81.7 months).

Conclusions: Our findings reflect the role of ischemic injury in the development of IC. However, other risk factors have been recognized in the literature. Due to the multifactorial nature of IC and the sample size of our study, further studies are warranted.

P297 Serial spleen stiffness measurement as a novel bedside prognostic biomarker in critically ill patients with cirrhosis

E Von Maldeghem, P Kalus, M Nanos, S Rusch, P Mester, V Pavel, M Müller-Schilling, STS Schmid

University Hospital Regensburg, Department of Internal Medicine I, Regensburg, Germany

Critical Care 2026, 30 (Suppl 1): P297

Introduction: Non-invasive elastography techniques are widely used to assess liver fibrosis and portal hypertension. While liver stiffness measurement is well established, spleen stiffness has emerged as a promising surrogate marker of portal hypertension. Evidence in critically ill patients—especially in those with cirrhosis or acute-on-chronic liver failure (ACLF)—remains limited. This study evaluated the feasibility of serial spleen stiffness assessment using acoustic radiation force impulse (ARFI) elastography in the intensive care unit (ICU) and explored its prognostic relevance.

Methods: In this prospective study, 44 ICU patients with chronic liver disease underwent ARFI-based spleen stiffness measurements every 48 h. Demographic data, organ support therapies and clinical outcomes were systematically collected.

Results: Serial ARFI measurements of spleen stiffness were feasible in all included patients. Higher spleen stiffness values showed a significant association with the requirement for renal replacement therapy ( p < 0.001) and invasive mechanical ventilation ( p < 0.001). Spleen stiffness demonstrated an inverse correlation with ventilatory pressure parameters ( p = 0.017). No correlation was observed with age, BMI or vasopressor support.

Conclusions: Serial spleen stiffness measurement using ARFI elastography is feasible, reproducible and robust in critically ill patients with cirrhosis. Beyond its role as a marker of portal hypertension, spleen stiffness reflects extrahepatic organ dysfunction and correlates with the development of organ failure. Dynamic spleen stiffness monitoring may therefore serve as a novel, non-invasive bedside biomarker to improve risk stratification and guide clinical decision-making in intensive care medicine.

P298 Preoperative and perioperative factors associated with ICU stay in cytoreductive surgery with intraperitoneal chemotherapy: secondary analysis with 2025

G Madrid 1 , D Diaz 1 , O Amaya 1 , A Romero 1 , A Ojeda 1 , J Gonzales 2 , DM Abril 2

1 Hospital Universitario Fundacion Santa Fe de Bogota, Anestesiologia, Bogotá, Colombia, 2 Universidad de los Andes, Bogotá, Colombia

Critical Care 2026, 30 (Suppl 1): P298

Introduction: Cytoreductive surgery with HIPEC requires substantial postoperative critical care resources. In 2023, our group reported that anesthetic technique, intraoperative bleeding, and extubation site were significant determinants of ICU length of stay (LOS) in this population. With the expansion of the institutional registry through 2025, we conducted a secondary analysis to validate and strengthen these findings using a larger cohort.

Methods: This study expanded the original cohort (n = 216, 2007–2022) to include 245 patients operated between 2023 and 2025, applying the same inclusion and exclusion criteria. ICU LOS was reexamined in relation to key perioperative variables: anesthesia technique, surgical and anesthetic duration, transfusion requirements, colloid administration, intraoperative blood loss, and extubation site. Statistical analyses included Mann–Whitney U, chi-square tests, and multivariable regression models.

Results: The enlarged dataset confirmed all previously reported associations. Total intravenous anesthesia (TIVA) remained independently associated with shorter ICU LOS (median 3 vs 4 days; p = 0.0001), and extubation in the operating room continued to demonstrate a protective effect (2 vs 3 days; p = 0.000). Surgical time, anesthetic duration, blood loss, and red blood cell transfusion volume were again positively correlated with longer ICU stay (all p < 0.001). Colloid selection, particularly albumin or Voluven, was consistently associated with prolonged ICU LOS. No new confounders emerged after increasing the cohort size.

Conclusions: This secondary analysis, incorporating additional patients and expanded follow-up, reinforces the robustness of our earlier findings. TIVA and early extubation continue to appear as modifiable perioperative factors associated with reduced ICU burden in HIPEC patients. The reproducibility of these associations across independent cohort expansions highlights their clinical relevance and supports their integration into perioperative management strategies.

P299 Prognostic scores for short- and long-term mortality in acute-on-chronic liver failure in intensive care

P Baptista, M Ferreira, T Cardoso, GC Campello

Unidade Local de Saúde Tâmega e Sousa, Serviço de Medicina Intensiva, Guilhufe, Portugal

Critical Care 2026, 30 (Suppl 1): P299

Introduction: Acute-on-chronic liver failure (ACLF) is a distinct entity from hepatic decompensation and often requires intensive care unit (ICU) admission. It affects 31% of patients with acute cirrhosis decompensation and carries higher mortality (34% versus 1.9%) [1,2]. Prognostic scores are essential to guide initiation and continuation of intensive care treatment in ACLF. This study describes ACLF episodes admitted to a secondary care ICU and evaluates general and specific prognostic scores for short- and long-term mortality.

Methods: Retrospective cohort of all ACLF cases admitted to the ICU of a secondary care hospital between January 2022 and December 2023. Discriminative performance of the Child–Pugh (CP) score, Model for End-Stage Liver Disease Sodium (MELD NA) score, Acute Physiology and Chronic Health Evaluation (APACHE II) score, Simplified Acute Physiology (SAPS II) score, and Chronic Liver Failure Consortium (CLIF-C) ACLF score was assessed using receiver operating characteristic (ROC) analysis.

Results: Among 80 patients with acute cirrhosis decompensation, 25% (n = 20) had ACLF. Their mean age ± SD was 55 ± 11 years, 75% were male, and 25% (n = 5) were referred for liver transplantation. At admission, 25% (n = 5) had grade 1, 35% (n = 7) grade 2, and 40% (n = 8) grade 3 ACLF. CP classes were 20% (n = 4) A, 20% (n = 4) B, and 60% (n = 12) C. Median (IQR) scores were: MELD NA 31 (22–36), SAPS II 45 (33–67), APACHE II 24 (19–24) and CLIF-C ACLF 52 (49–59). Mortality in ICU, in hospital, at 28 days and at 1-year was 30% (n = 6), 50% (n = 10), 55% (n = 11) and 65% (n = 13), respectively. The overall performance of the scores is summarized in the Table.

Conclusions: In this cohort, SAPS II best predicted ICU mortality, while CLIF-C ACLF was superior for hospital and long-term mortality. The specific scores like CP and MELD-NA, calculated in the first 24 h of admission, were not useful for this particular propose. Table (abstract P299) Performance of prognostic scores

References Moreau R et al. Gastroenterology 2013;144:1426–37 Dong V et al. JHEP Rep 2019;1:44–52

P303 Intensive care during liver retransplantation with a temporary portocaval shunt due to primary graft non-function

P Prylutski 1 , I Makhanouski 2 , A Dzyadzko 3 , A Scherba 3

1 Minsk Scientific and Practical Center for Surgery, Transplantology and Hematology, Department of Anesthesia and Intensive Care No.2 for Surgical Patients, Minsk, Belarus, 2 Minsk Scientific and Practical Center for Surgery, Transplantology and Hematology, Department of Anesthesiology and Intensive Care No.5 for Cardiosurgical Patients, Minsk, Belarus, 3 Minsk Scientific and Practical Center for Surgery, Transplantology and Hematology, Minsk, Belarus

Critical Care 2026, 30 (Suppl 1): P303

Introduction: Despite significant advancements in transplantation, perioperative therapy, and immunosuppression, primary graft non-function (PGNF) remains one of the most dangerous complications of this surgery as the recipient cannot survive without urgent retransplantation.

Methods: The intensive care experience of 4 patients with PGNF and a temporary portocaval shunt (TPCS) is described. PGNF criteria were taken from the Organ Procurement and Transplantation Network Policies (2020). All patients underwent hepatectomy and TPCS with liver retransplantation due to the development of toxic liver syndrome. During TPCS, complete liver function replacement therapy was conducted similarly to acute liver failure management.

Results: Patient characteristics are presented in the Table. Twelve hours after liver transplantation and development of PGNF, patients showed: Vasopressor Index Score 85.5 ± 43.68, AST 10,448 ± 13,687.78 U/L, AT3 35.25 ± 24.78%, INR 2.02 ± 0.36, Lac 13.32 ± 4.12 mmol/L. During TPCS, all patients underwent therapeutic plasma exchange (fresh frozen plasma, at rate of 1.5–2 volumes of circulating plasma), continuous renal replacement therapy (CRRT), and coagulopathy correction with help of thromboelastometry. Prerequisites for a positive outcome included early retransplantation (within 12 h after TPCS), absence of systemic infection (carbapenem-resistant flora), absence of combined functional deficit (physiological or due to prolonged multiple organ dysfunction syndrome), and a positive systemic response to hepatectomy.

Conclusions: The use of hepatectomy with TPCS and rational intensive care therapy is the only effective method to stabilize homeostasis while awaiting retransplantation under a clear management strategy. Table (abstract P303) Patient characteristics

P306 Urinary albumin-to-creatinine ratio for prediction of acute kidney injury: a systematic review and meta-analysis

N Kitisin 1 , A Serpa Neto 2 , N Raykateeraroj 1 , J Ismail 2

1 Faculty of Medicine, Siriraj Hospital, Mahidol University, Department of Anesthesiology, Bangkok, Thailand, 2 Department of Intensive Care, Austin Hospital, Heidelberg, Victoria, Australia

Critical Care 2026, 30 (Suppl 1): P306

Introduction: The urine albumin-to-creatinine ratio (UACR) is a well-established marker of chronic kidney disease, but its utility for predicting acute kidney injury (AKI) in hospitalized adults remains uncertain. We evaluated UACR performance for predicting AKI incidence and progression.

Methods: We performed a PRISMA-compliant systematic review and meta-analysis [1] (PROSPERO CRD420250648041) of studies in adults (≥ 18 years) assessing UACR for AKI incidence or progression. Ovid MEDLINE, Embase and CENTRAL were searched to February 2025. Random-effects models pooled odds ratios (ORs), sensitivity, specificity and constructed a summary receiver operating characteristic (sROC) curve.

Results: Sixteen studies were included (13 AKI incidence; 3 AKI progression), enrolling 10,438 and 1,596 patients, respectively, across settings including cardiac surgery, sepsis, COVID-19, acute myocardial infarction and cirrhosis. Elevated UACR was associated with increased risk of AKI development (8 studies; pooled OR 1.45, 95% CI 1.10–1.90). Pooled sensitivity and specificity for AKI prediction were 0.71 (95% CI 0.59–0.80) and 0.67 (95% CI 0.56–0.76), with sROC area under the curve 0.74 (95% CI 0.64–0.84), indicating moderate diagnostic accuracy (Figure). In cardiac surgery patients, elevated UACR consistently predicted AKI (3 studies; pooled OR 1.56, 95% CI 1.14–2.15). For AKI progression, elevated UACR strongly predicted worsening stage (3 studies; pooled OR 3.76, 95% CI 2.59–5.45).

Conclusions: Elevated UACR is significantly associated with both development and progression of AKI in hospitalized adults and shows moderate diagnostic accuracy, particularly in cardiac surgery. Given its low cost, non-invasiveness and wide availability, UACR is a promising candidate for early AKI risk stratification; standardized thresholds and further validation are needed before routine implementation. Figure (abstract P306) Each numbered circle represents an individual study included in the meta-analysis. The red diamond marks the summary operating point, reflecting pooled sensitivity and specificity estimates. The solid black curve denotes the fitted sROC curve. The shaded blue ellipse illustrates the 95% confidence region, while the dashed blue contour indicates the 95% prediction region. The overall area under the curve (AUC) was 0.739 (95% CI: 0.641–0.837), indicating moderate diagnostic performance of UACR for predicting AKI. Pooled sensitivity and specificity were 0.707 (95% CI: 0.589–0.803) and 0.668 (95% CI: 0.561–0.760), respectively

Reference Page MJ et al. J Clin Epidemiol 2021;134:178–189

P308 Hydrogen alleviates sepsis-associated acute kidney injury by enhancing mitophagy to inhibit STING-dependent cellular senescence

S Pei 1 , K Xie 2

1 Tianjin Medical University General Hospital, Tianjin, China, 2 Tianjin Medical University General Hospital, Department of Critical Care Medicine, Tianjin, China

Critical Care 2026, 30 (Suppl 1): P308

Introduction: Specific therapies for sepsis-associated acute kidney injury (SA-AKI) are limited. While cellular senescence contributes to its pathology, its initiating mechanisms remain poorly defined. We hypothesized that hydrogen (H₂) confers protection in SA-AKI by alleviating cellular senescence through modulation of the STING pathway.

Methods: We employed a murine cecal ligation and puncture (CLP) model and LPS-stimulated human renal tubular (HK-2) cells. Senescence was evaluated via SA-β-Gal staining, p16/p53 expression, EdU incorporation, and SASP. In vivo outcomes included survival and renal function. STING, identified through transcriptomics, was validated in SA-AKI patient serum. Functional studies used STING agonist (diABZI), knockout mice, siRNA, and the mitophagy inhibitor 3-MA. MtDNA cytosolic release, cGAS-STING-NF-κB signaling, and mitophagy were analyzed.

Results: SA-AKI models exhibited a pronounced senescent phenotype. H₂ inhalation significantly improved survival, restored renal function, and attenuated senescence and tissue injury. STING was upregulated in SA-AKI and suppressed by H₂. Crucially, STING activation abolished H₂’s benefits, whereas STING deficiency reproduced its anti-senescent effects. We demonstrated that LPS-induced mitochondrial damage provoked mtDNA release, activating the cGAS-STING-NF-κB cascade. H₂ augmented mitophagy, which cleared damaged mitochondria and cytosolic mtDNA. All protective effects of H₂ were reversed by 3-MA.

Conclusions: This study defines a novel pathogenic pathway in SA-AKI where mitochondrial damagepromotes STING-driven cellular senescence. Hydrogen protects by enhancing mitophagy to interrupt this pathway (Figure), positioning mitophagy augmentation as a compelling therapeutic strategy. Figure (abstract P308) The schematic illustrates the proposed mechanism without (Left Panel) and with (Right Panel) hydrogen (H₂) treatment

P310 Risk factors and outcomes of postoperative acute kidney injury in acute type A aortic dissection surgery

N Raykateeraroj 1 , K Raksamanee 1 , H Mayingo 1 , L Weinberg 2

1 Faculty of Medicine Siriraj Hospital, Mahidol University, Department of Anesthesiology, Bangkok, Thailand, 2 Austin Hospital, Department of Anesthesiology, Heidelberg, Victoria, Australia

Critical Care 2026, 30 (Suppl 1): P310

Introduction: This study aimed to determine the incidence, independent risk factors, and clinical outcomes of postoperative acute kidney injury (AKI) in patients undergoing surgery for acute type A aortic dissection (ATAAD), a complication associated with high mortality [1–3].

Methods: We conducted a retrospective cohort study of adult patients undergoing ATAAD repair between 2017 and 2023. Patients with end-stage renal disease were excluded. AKI was defined by Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Multivariable logistic regression identified independent risk factors.

Results: Of 246 patients, 99 (40.2%) developed postoperative AKI. Multivariable analysis identified pre-existing chronic kidney disease (CKD) and preoperative vasoactive-inotropic score (VIS) as independent predictors (Table). Patients with AKI had significantly higher rates of in-hospital mortality (18.2% vs 3.4%; p < 0.001) and 30-day mortality (15.2% vs 2.7%; p < 0.001). The AKI group also experienced prolonged mechanical ventilation (median 76 vs 41 h; p < 0.001) and longer intensive care unit (ICU) length of stay (median 7 vs 3 days; p < 0.001).

Conclusions: Postoperative AKI is common in ATAAD surgery and significantly impacts survival and resource utilization. Preoperative renal dysfunction and hemodynamic instability requiring inotropes are key predictors.

References Wang W et al. Interact Cardiovasc Thorac Surg 2021;32:81–89 Ko T et al. Am J Cardiol 2015;116:463–8 Roh GU et al. Ann Thorac Surg 2012;94:766–71

Table (abstract P310) Results Data are presented as odds ratios (ORs) with 95% confidence intervals (CIs). Continuous variables were modeled per unit increase as specified. * p value < 0.05 indicates statistical significance. Abbreviations: AKI, acute kidney injury; BMI, body mass index; CKD, chronic kidney disease; CPB, cardiopulmonary bypass; MAP, mean arterial pressure.

P311 Hemoadsorption therapy in rhabdomyolysis: report of the international, prospective COSMOS registry

J Kreutz 1 , C Scharf 2 , B Tyczynski 3 , R Ferrer 4 , M Unglaube 5 , D Henzler 6 , P Hohlstein 7 , N Malewicz Oeck 8 , T Klaus 9 , FS Taccone 10

1 University Hospital, Philipps University of Marburg, Department of Cardiology, Angiology, and Intensive Care Medicine, Marburg, Germany, 2 LMU, Department of Anesthesiology, Munich, Germany, 3 University Clinic Essen, Department of Medical Intensive Care, Essen, Germany, 4 Vall d´Hebron University Hospital, Shock, Organ Dysfunction and Resuscitation Research Group SODIR, Intensive Care Department, Barcelona, Spain, 5 Helios Dr. Horst Schmidt Klinik Wiesbaden, Department of Intensive Care, Wiesbaden, Germany, 6 Ruhr University Bochum, Klinikum Herford, Department of Anesthesiology, Surgical Intensive Care, Emergency and Pain Medicine, Herford, Germany, 7 RWTH University Hospital Aachen, Department for Gastroenterology, abolic Disorders and Intensive Care Medicine Department of Medicine III, Aachen, Germany, 8 BG University Hospital Bergmannsheil, Medical Faculty of Ruhr University Bochum, Department of Anesthesiology, Surgical Intensive Care, Emergency and Pain Medicine, Bochum, Germany, 9 CytoSorbents Europe GmbH, Critical Care, Berlin, Germany, 10 Hôpital Universitaire de Bruxelles HUB, Université Libre de Bruxelles ULB, Department of Intensive Care, Brussels, Belgium

Critical Care 2026, 30 (Suppl 1): P311

Introduction: Rhabdomyolysis with markedly elevated myoglobin is associated with acute kidney injury (AKI) and mortality. CytoSorb (CS) hemoadsorption has been used to remove myoglobin, but evidence remains limited. This study evaluated whether CS could reduce circulating myoglobin and therefore help to mitigate renal complications.

Methods: The COSMOS Registry ( NCT05146336 ) is a prospective, international observational study assessing CS hemoadsorption in critically ill patients. Data were collected 24 h before and after CS therapy, at ICU and hospital discharge, 90 days post-treatment. Changes in biomarkers were analysed with Wilcoxon signed-rank test. Results are reported as median [Q1, Q3] or mean ± SD. Only patients with fully monitored data were included in the analysis.

Results: Forty-five patients (mean age 56 ± 20 years; 29% female; 11% trauma-induced) with rhabdomyolysis from 14 centers in 4 countries were included. Median APACHE II was 24 [18, 30]; 33% had pre-existing renal dysfunction (KDIGO 3 [1.5, 3.5]). CS was integrated into renal replacement therapy (RRT) in 88.6% and used stand-alone in 11.4%. Treatment significantly reduced median myoglobin (from 8,798 [4,232, 30,000] to 2,959 [774, 6,735] µg/L; p < 0.0001), with the percentage of critically elevated levels (> 10,000 µg/L) decreasing from 48.3% to 10.3% ( p < 0.0001, Figure). CK (9,826 [2,390, 31,273] to 4,130 [1,046, 8,764] IU/L; p < 0.0001) and creatinine (2.3 [1.5, 3.6] to 1.8 [1.1, 2.8] mg/dL; p = 0.0004) also decreased. Median ICU stay was 15 [9, 26] days and RRT duration 10 [4, 12] days. 32 (71.1%) out of 45 patients survived from ICU stay. The percentage of patients remaining dialysis dependent declined from 25% at ICU discharge to 8% at 90-days. No serious device-related adverse events occurred.

Conclusions: CS hemoadsorption is associated with significant myoglobin reduction and may help to improve renal function in rhabdomyolysis. These real-world results require confirmation in controlled studies. Figure (abstract P311) Patient-level, pre- to post-CS myoglobin level

P312 Development of a prediction score for continuous kidney replacement therapy-related hypothermia

P Chummano 1 , T Thongkam 1 , N Chansatchanali 1 , Y Sonprasom 1 , K Trongtrakul 2 , W Sirikul 3

1 Chiang Mai University, Faculty of Medicine, Chiang Mai, Thailand, 2 Chiang Mai University, Department of Internal Medicine, Faculty of Medicine, Chiang Mai, Thailand, 3 Chiang Mai University, Department of Community Medicine, Faculty of Medicine, Chiang Mai, Thailand

Critical Care 2026, 30 (Suppl 1): P312

Introduction: Hypothermia is a common complication during continuous kidney replacement therapy (CKRT) and is associated with an increased mortality in critically ill patients. Due to the lack of practical prediction tools, this study aimed to develop CKRT-related hypothermia prediction score to facilitate early identification and guide clinical management.

Methods: We conducted a retrospective cohort study of critically ill patients who commenced CKRT in the 11-bed Medical Intensive Care Unit at the Faculty of Medicine, Chiang Mai University, between February 2018 and August 2024. Hypothermia was defined as a body temperature below 35 °C within the first 48 h of CKRT initiation. Potential predictors were identified using multivariable logistic regression analysis. Model calibration was assessed using the Hosmer–Lemeshow (HL) test and internal validation was performed using a 1,000-replication bootstrapping method.

Results: Among 214 patients (mean age 65 ± 17 years, 38.3% female, and APACHE II 28 ± 6), 51.9% (111 cases) experienced CKRT-related hypothermia. The predictors included in the final model and their assigned scores were: respiratory failure at ICU admission (+ 13 points), APACHE II score (1.5 points per point), pre-CKRT body temperature (-1 point per 0.1 °C increased), serum creatinine (-2 points per mg/dL increase), and level of total bilirubin (+ 1 point per mg/dL increase) (Table). The total score demonstrated good discrimination, with a C-statistic of 0.78; 95% CI 0.72–0.84. Model calibration ( p = 0.47) indicated accepTable fit, and internal validation confirmed stable performance, with a C-statistic of 0.78; 95% CI, 0.71–0.84, p < 0.001.

Conclusions: Our prediction score demonstrated good discriminative performance in identifying patients with high risk for CKRT-related hypothermia in the derivation cohort. However, external validation is necessary to confirm its effectiveness and generalizability in clinical practice. Table (abstract P312) Predictive factors and scoring for hypothermia risk during continuous kidney replacement therapy (CKRT)

P313 Citrate anticoagulation in continuous renal replacement and effect on calcium balance: a single centre retrospective analysis

M Barker 1 , B Sanderson 2 , L Tovey 2 , M Khosravi 2

1 Guys and St Thomas NHS Foundation Trust, Pharmacy/Critical Care, London, UK, 2 Guys and St Thomas NHS Foundation Trust, Critical Care, London, UK

Critical Care 2026, 30 (Suppl 1): P313

Introduction: There is limited information about total body calcium balance in patients receiving prolonged continuous renal replacement therapy (CRRT) with citrate anticoagulation. A small cohort study suggests there may be a deficit in total calcium over time, risking demineralisation and fractures [1]. This may be heralded by a reduction in rate of calcium compared to citrate infusion over time.

Methods: We conducted a retrospective chart review to determine the effect of CRRT duration on the citrate/calcium infusion rates, ratios, and association with select patient characteristics (Table). Calcium and citrate rates and patient data were extracted from our clinical information system for patients who received citrate CRRT between Jan 2018 to 2023. Calcium/citrate ratios were calculated and a mixed linear regression model used to determine the effects of time on the ratio of citrate to calcium and association with the other selected demographics.

Results: 2,207 patients where found to have received citrate CRRT. Patients received citrate CRRT for a median of 5 days (IQR 3,11). Other demographics are shown in the Table. The fixed effect of time on Citrate/calcium infusion ratio was estimated to be an increase of 0.5 (95%CI: 0.4–0.7) every 28 days ( p < 0.001). No association was found with any of the selected patient demographics, except ionised calcium.

Conclusions: There was a statistically significant increase in citrate/calcium ratio over time. The magnitude of this 0.5 increase over a short number of days is small and unlikely to be clinically significant for the majority of patients. Patients on citrate CRRT for several months however may be at risk, so further studies in this cohort are required.

Reference De Jonge E et al. J Nephrol 2022;36:1019–1026

Table (abstract P313) Patient demographics

P314 A post-market clinical performance and safety evaluation of GamCath High-Flow Dolphin Protect catheter

J Echeverri 1 , W Dabrowski 2 , M Winiarz 3 , M Szukala 2 , M Peters 4 , K Harenski 5 , T Kudelka 4 , M Zammit 4 , B Keller 4

1 Vantive U.S Healthcare LLC, Global Medical Affairs, Deerfield, USA, 2 First Department of Anaesthesiology and Intensive Therapy Medical University of Lublin, Lublin, Poland, 3 Independent Public Health Care Unit, Leczna, Poland, 4 Vantive U.S Healthcare LLC, Deerfield, USA, 5 Vantive Health Germany GmbH, Unterschleißheim, Germany

Critical Care 2026, 30 (Suppl 1): P314

Introduction: Catheters are essential in acute therapy, but their safety profile is often underestimated. Catheter-related complications can lead to reduced catheter survival, which may compromise patient safety and reduce therapy efficacy. This study evaluated the real-world safety and performance of Gamcath Highflow Dolphin Protect Catheters; a type of coated catheter designed to prolong catheter survival and reduce the risk of infection.

Methods: A retrospective review of medical records was conducted for adult patients who received the Gamcath Dolphin Catheter for extracorporeal blood purification from 2018 to 2024 in 2 intensive care units in Poland. The catheters were inserted through jugular or femoral veins. Data on catheter survival, removal reasons, and patient outcomes were collected. Catheter survival was assessed using time-to-event analysis; removal due to complications was considered an event, while other outcomes were censored.

Results: Records of 75 patients were analysed; most were male (76.0%), with a mean age of 63.7 years. Primary diagnoses were acute renal failure (n = 33) or acute kidney injury (n = 30). Overall, 130 catheters were placed, of which only 9 (6.9%) were removed due to an event (Table). Notably, 12 catheters remained in place for at least 25 days, and 5 remained in place for at least 30 days. As fewer than 50% of catheters were removed due to an event, the median survival time was not reached. Thirty-three (44.0%) patients experienced 37 adverse events (21.8 events per 1000 catheter days), 36 of which were serious (21.3 events per 1000 catheter days) while 4 (infection, sepsis, and product issue) were related to the study device. Thirty patients (40.0%) died with the catheter in-place; none of these deaths were study device related.

Conclusions: These results support the performance and safety of Gamcath Highflow Dolphin Protect catheters, showing a low rate of complication-related removals and prolonged catheter survival over time. Table (abstract P314) Reported outcomes

P315 A computational approach for early detection of citrate accumulation in continuous kidney replacement therapy

MM Müller 1 , D Hansel 2 , J Bachmann 3 , J Bartussek 3 , O Sazpinar 3 , R Pohlmeier 2 , S David 3

1 University Hospital Zürich, Institute of Intensive Care Medicine, Zürich, Switzerland, 2 Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany, 3 University Hospital Zürich, Zürich, Switzerland

Critical Care 2026, 30 (Suppl 1): P315

Introduction: The aim of this study was to: (1) determine the incidence of citrate accumulation (CA) during CKRT with regional citrate anticoagulation (RCA); (2) evaluate its association with clinical outcomes; and (3) assess whether a computational algorithm developed to predict bicarbonate levels during CKRT can identify patients at risk of CA using the difference between predicted and measured bicarbonate levels (ΔHCO₃⁻).

Methods: This retrospective study included critically ill patients at the University Hospital Zurich (USZ) receiving CKRT. CA was assessed using three definitions: (1) the local USZ standard of an albumin-corrected total-to-ionised calcium ratio (T/iCa) ≥ 2.5; (2) the Meier-Kriesche definition of a T/iCa > 2.5 without albumin correction; and (3) the Khadzhynov criteria combining T/iCa without albumin correction with hypocalcaemia and metabolic acidosis. The predictive performance of ΔHCO₃⁻ for CA was evaluated using AUROC.

Results: Among 1,077 included patients, 153 (14%), 36 (3%), and 12 (1%) fulfilled the criteria for CA according to the USZ, Meier-Kriesche, and Khadzhynov criteria, respectively (Figure, panel A). CA occurred after a median of 8 [IQR 5–16], 9 [IQR 5–28], and 6 h [IQR 4–15] from CKRT initiation, according to the respective definitions. The corresponding ICU mortality rates were 65%, 83%, and 100%, compared with 39% in the overall cohort. After multivariable adjustment, all three definitions remained independently associated with ICU mortality. ΔHCO₃⁻ showed the highest discriminative ability for CA 4 h after CKRT initiation, with AUROC values of 0.72 (USZ), 0.83 (Meier-Kriesche), and 0.97 (Khadzhynov). Optimal ΔHCO₃⁻ thresholds were 2.06 (USZ), 2.83 (Meier–Kriesche), and 4.86 mmol/L (Figure, panel B).

Conclusions: The incidence of CA varies substantially by definition, is associated with adverse outcomes, and can be detected early using a bicarbonate prediction algorithm. Prospective validation is required to confirm the algorithm’s accuracy in clinical practice. Figure (abstract P315) (A) Incidence proportion of citrate accumulation (CA) according to the three investigated definitions: the University Hospital Zürich definition, the Meier-Kriesche definition, and the Khadzhynov definitions. (B) Area under the ROC curve (AUROC) of the bicarbonate-prediction algorithm for detecting CA based on the same three definitions, using the difference between predicted and true measured bicarbonate levels (ΔHCO₃⁻)

P316 Development of a predictive model and nomogram to predict the need of renal replacement therapy at the intensive care unit

A Oliveira, J Luís, AM Oliveira, A Marques, R Curto, J Gonçalves-Pereira

Hospital de Vila Franca de Xira, ICU, Vila Franca de Xira, Portugal

Critical Care 2026, 30 (Suppl 1): P316

Introduction: Acute kidney injury requiring renal replacement therapy (RRT) significantly affects outcomes in critically ill patients. Early identification of patients who will need RRT may improve prognosis. We developed a predictive model and a bedside nomogram using early ICU variables to estimate the probability of RRT.

Methods: We conducted a retrospective study of ICU patients admitted between 2015 and 2023. Clinical and laboratory parameters collected in the first 48 h were analysed. A multivariate logistic regression analysis was used to select six independent predictors: creatinine, serum potassium, arterial pH, urine output, base excess (BE), and SAPS II. Model performance was assessed using ROC analysis and optimal threshold determination.

Results: In this study, 5830 patients admitted to a general ICU were enrolled (56.8% male; mean age 65.5 ± 16.7 years). Creatinine was the strongest predictor of RRT, followed by potassium and pH; urine output also showed a relevant impact, while base excess and SAPS II had moderate effects. The model demonstrated excellent discrimination (AUC 0.900, 95% CI 0.892–0.908), good calibration, yielding a sensitivity of 84.7% and a specificity of 83.2%. A nomogram based on the six predictors was generated for bedside application [1] (Figure).

Conclusions: Early ICU data can accurately predict the need for RRT [2]. The proposed nomogram enables rapid clinical risk stratification, supporting timely decision-making and resource allocation in critical care. Figure (abstract P316) Nomogram for RRT probability based on six independent predictors (creatinine, potassium, pH, urine output, base excess, SAPS II)

References Hong H et al. Health Data Science 2023:3;0023 Li X etal. Crit Care 2021;25:15

P317 A transparent machine learning model for predicting CRRT requirement in patients with sepsis-associated acute kidney injury: a multi-center retrospective study

F Mingxing 1 , Y Tang 2

1 Hebei Medical University Third Hospital, Intensive Care Unit, China, 2 Hebei Medical University Third Hospital, China

Critical Care 2026, 30 (Suppl 1): P317

Introduction: Sepsis-associated acute kidney injury (SA-AKI) has high mortality, and identifying patients requiring continuous renal replacement therapy (CRRT) remains challenging. This study developed and validated an interpretable machine learning (ML) model to predict CRRT need in SA-AKI.

Methods: Adult patients meeting Sepsis-3 and KDIGO-AKI criteria were extracted from MIMIC-IV (n = 5,568) and eICU-CRD (n = 4,825). Twenty-nine early variables were used to train eight ML models. Performance was assessed by AUC and F1-score. SHAP was applied for interpretability. External validation and a simplified nomogram were included.

Results: Linear Discriminant Analysis (LDA) performed best (AUC 0.933). A reduced 7-feature model (creatinine, SOFA, AKI stage, lactate, hematocrit, urine output, SpO₂) preserved high accuracy and achieved an AUC of 0.833 externally. SHAP identified creatinine and lactate as major contributors. Using a 28.06% cutoff, subgroup analysis showed high mortality in true positives (56.5%) and notably elevated mortality in false positives (45.7%), indicating a high-risk phenotype missed by current criteria (Figure). A nomogram and online calculator were created.

Conclusions: We developed a robust and interpretable ML model for early CRRT prediction in SA-AKI. The model generalized well across centers and identified clinically vulnerable subgroups, supporting more timely and precise renal support. Figure (abstract P317) 28-day mortality across true negative (TN), false positive (FP), true positive (TP), false negative (FN) groups

P318 Impact of sex on renal replacement therapy initiation, a multicenter observational study

I Lemagnen 1 , B Trachsel 2 , B Brunoni 1 , T Kelevina 1 , A Schneider 1

1 Centre Hospitalier Universitaire Vaudois CHUV, Adult Intensive Care Unit, Lausanne, Switzerland, 2 Center for Primary Care and Public Health Unisanté, Department of Epidemiology and Health Systems, Quantitative Research, Lausanne, Switzerland

Critical Care 2026, 30 (Suppl 1): P318

Introduction: The impact of sex on the decision to initiate renal replacement therapy (RRT) in critically ill patients with acute kidney injury (AKI) remains unclear.

Methods: We studied patients admitted to the intensive care unit (ICU) for > 6h in two cohorts Laus’AKI (Lausanne, 2010–2020, derivation) and MIMIC-IV (Boston, 2008–2019, validation). We excluded those with chronic dialysis, kidney transplant or intoxication. We collected demographics, comorbidities, SAPS II score, laboratory values, AKI stage and criteria for RRT initiation (based on potassium, pH, fluid balance diagnosis and PaO₂/FiO₂) within 24 h of ICU admission. We considered acute kidney disease (AKD), dialysis dependence, and mortality as outcomes. We assessed the influence of sex on RRT initiation, adjusted for age, objective dialysis criteria, KDIGO stages, selected SAPS II subcomponents, and admission diagnosis. Outcomes were analyzed using a propensity score for RRT receipt. Analyses were repeated in patients with stage ≥ 2 AKI and after stratification for age.

Results: We analyzed 14,980 patients (1,040 dialyzed: 719 men (69%), 321 women (31%)) from the Laus’AKI cohort and 48,362 patients (1,123 dialyzed: 676 men (60%), 447 women (40%)) from the MIMIC-IV. In both cohorts, male sex was associated with higher odds of RRT (OR Laus’AKI 1.20, [95% CI 1.01–1.43] and MIMIC-IV 1.29, [95%CI 1.10–1.51]). Sensitivity analyses confirmed our main results. No statistically significant differences were observed between sexes in patients undergoing RRT with regards to AKD occurrence or dialysis dependence. Furthermore, receipt of RRT did not influence the association between sex and mortality (p-value for interaction > 0.05 in the validation cohort).

Conclusions: Male ICU patients are more likely to receive RRT than females, however this appears not to impact their outcomes.

P319 NRS 2002 predictive validity in critically ill patients who receive renal replacement therapy

NG Russo 1 , NL Mattos 2 , E Colonnezi 2 , A Yamaguti 3 , LU Taniguchi 2

1 Hospital Beneficente de Senhoras SírioLibanês, Nutrition / Intensive Care Unit, São Paulo, Brazil, 2 Hospital Beneficente de Senhoras SírioLibanês, Intensive Care Unit, São Paulo, Brazil, 3 Hospital Beneficente de Senhoras SírioLibanês, Nutrition, São Paulo, Brazil

Critical Care 2026, 30 (Suppl 1): P319

Introduction: Nutritional risk screening 2002 (NRS 2002) is a common screening tool of malnutrition in intensive care units (ICU), but its accuracy to predict mortality might be influenced by the necessity of invasive support. Since renal replacement therapy (RRT) is frequently used to support ICU patients, we aimed to describe the ability of NRS 2002 to predict hospital mortality in this subgroup.

Methods: We performed a retrospective cohort study of all adult (> 18 years) patients admitted to an ICU of Hospital Sírio-Libanês (São Paulo, Brazil) from 2022 to 2024. NRS 2002 was calculated in the first 24 h of ICU admission. Discrimination and predictive ability of this tool for hospital mortality were evaluated with area under ROC curves and logistic regression, adjusting for age, sex, SOFA score, status performance, Charlson Comorbidity Index, and type of ICU admission. Test for interaction between NRS 2002 ≥ 3 and RRT (RRT group vs. no-RRT group) was performed in the logistic regression.

Results: The cohort included 4,809 patients (315 received RRT). Prevalence of NRS 2002 ≥ 3was 45.1% (95% confidence interval [CI] 43.7%–46.5%), higher in the RRT group (68.6%,95% CI 63.1%–73.7%) compared with the no-RRT group (43.5%, 95% CI 42.0%–44.9%, p < 0.001). Predictive validity of NRS 2002 for hospital mortality was heterogeneous according to RRT ( p value for heterogeneity = 0.007): odds ratio 2.21 (95% CI 1.68–2.92, p < 0.001) for no-RRT group, and odds ratio 0.94 (95% CI 0.53–1.65, p = 0.83) for RRT group. ROC curves were different according to RRT subgroups ( p < 0.001): 0.74 (95% CI 0.72–0.75) for no-RRT group, and 0.52 (95% CI 0.46–0.57) for RRT group. Sensitive analysis of NRS 2002 predictive validities for hospital mortality according to mechanical ventilation ( p = 0.59) and vasopressors( p = 0.65) did not demonstrate heterogeneity for these subgroups.

Conclusions: NRS 2002 did not demonstrate predictive validity for hospital mortality in our cohort of patients who received RRT.

P321 Comparison of lactate clearance between continuous renal replacement therapy (CRRT) modalities

F Magon, F Mani, B Brunoni, M Caramella, F Zadek, T Langer

Università Statale di MilanoBicocca, Anesthesia and Critical Care, Niguarda Hospital, Milan, Italy

Critical Care 2026, 30 (Suppl 1): P321

Introduction: Lactate reduction is a key target within the resuscitation bundles recommended by the Surviving Sepsis Campaign [1]. However, little is known about lactate clearance during continuous renal replacement therapy (CRRT) and the specific contribution of veno-venous hemofiltration (CVVH) and continuous veno-venous hemodialysis (CVVHD). To address these gaps, we conducted a prospective observational study to compare lactate mass clearance in patients treated with CVVH or CVVHD.

Methods: We performed a single-center, prospective observational study including adult oligo-anuric ICU patients with a clinical indication for CRRT. Blood gas analyses were obtained before and after the filter and in the ultrafiltrate/dialysate. Lactate content in plasma water and effluent was calculated as previously described [2].

Results: Forty-six patients were enrolled: 24 treated with CVVH and 22 with CVVHD. Baseline lactate concentrations were similar between groups (1.6 [1.1–3.5] mmol/L for CVVH vs 2.0 [1.2–3.9] mmol/L for CVVHD, p = 0.76). Lactate ultrafiltrate/dialysate rates were similar during CVVH and CVVHD (0.08 [0.05–0.15] and 0.08 [0.06–0.17] mmol/min, respectively, p = 0.58) (Figure, panel a). The relationship between the inlet lactate load and the corresponding lactate mass clearance was assessed. Linear regression revealed a markedly steeper slope for CVVH compared with CVVHD, indicating substantially higher efficiency of CVVH in removing lactate for any given inlet load ( p < 0.0001) (Figure, panel b).

Conclusions: CVVH and CVVHD provide similar absolute lactate effluent removal. However, when assessed using a mass-balance approach, CVVH shows significantly greater lactate clearance efficiency for a given inlet load. These findings suggest that the choice of CRRT modality may influence lactate handling in critically ill patients. Figure (abstract P321) The box plot on the left shows comparable effluent lactate flow rates between CVVH and CVVHD. The scatter plot on the right displays the relationship between lactate inlet load (Q_lac in) and lactate mass clearance (Q_lac eff), with linear regression demonstrating a significant difference in slope between the two modalities

References Evans L et al. Intensive Care Med 2021;47:1181–247 Jimenez EV et al. Nephron 2021;145:91–8

P322 Hypokalemia with diluted regional citrate anticoagulation during continuous renal replacement therapy in critically ill patients

F Mani, F Magon, B Brunoni, M Caramella, F Zadek, T Langer

University of MilanBicocca, Department of Medicine and Surgery, Monza, Italy

Critical Care 2026, 30 (Suppl 1): P322

Introduction: Acute kidney injury (AKI) affects up to two-thirds of critically ill patients, and about 20% of them require continuous renal replacement therapy (CRRT) [1, 2]. Diluted regional citrate anticoagulation (dRCA) is widely used to maintain circuit patency and reduce bleeding risk [3]. However, because dRCA is potassium-free and infused in substantial volumes, it may alter potassium (K + ) balance. This study evaluated the effect of dRCA on serum potassium concentration [K + ] in different CRRT modalities.

Methods: We analyzed both in-vitro and in-vivo (ST150 filter, Baxter) different CRRT modalities performed with dRCA (Regiocit, Baxter) combined with 4 mmol/L K + containing dialysate/replacement fluids (Biphozyl or Phoxilium, Baxter). K + concentration was measured using a blood gas analyzer, in-vitro at baseline and after reaching a stable value, i.e., after 210 min, while in-vivo at start and after 72 h of treatment.

Results: Regardless of the technique employed, in-vitro experiments performed with dRCA (n = 12) resulted in significant hypokalemia. In contrast, when systemic heparin anticoagulation was used instead of dRCA (n = 8), [K + ] matched those of the dialysate or replacement solution (Figure). In the in-vivo experiments, using exclusively dRCA, patients treated with CVVH (n = 24) or CVVHD n = 11) had [K + ] at 72 h of 4.0 ± 0.3 mEq/L ( p < 0.01) and 3.9 ± 0.4 mEq/L ( p < 0.01), respectively. In both modalities, patients required intravenous K + supplementation during the 72 h (159 ± 104 mEq CVVH vs. 96 ± 51 mEq CVVHD, p = 0.07).

Conclusions: CRRT performed with dRCA requires substantial intravenous K + supplementation to avoid hypokalemia. Figure (abstract P322) In-vitro experiments representing both baseline and potassium concentration reached at equilibrium (data are expressed as mean ± SD). Red dots represent experiments performed with dRCA, while white dots represent experiments performed using heparin

References Stevens P et al. Kidney Int 2024;105:S117-S314 Bagshaw S et al. Intensive Care Med 2017;43:841–854 Zarbock A et al. JAMA 2020;324:1629–1639

P325 Evaluation of the furosemide stress test to predict successful liberation from renal replacement therapy in critically ill patients

T Soccorsi 1 , B Trächsel 2 , I Lemagnen 3 , C Monard 4 , A Schneider 5

1 Centre Hospitalier Universitaire Vaudois CHUV, Service de Médecine Intensive Adulte, Lausanne, Switzerland, 2 Department of Epidemiology and Health Systems, Center for Primary Care and Public Health Unisanté, Lausanne, Switzerland, 3 Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland, 4 Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France, 5 Centre Hospitalier Universitaire Vaudois CHUV, Lausanne, Switzerland

Critical Care 2026, 30 (Suppl 1): P325

Introduction: Furosemide is commonly administered to assess patients’ potential for RRT liberation; however, the standardized furosemide stress test (FST [1]) was not formally evaluated. We aimed to determine FST’s ability to predict RRT liberation within 72 h.

Methods: This single-center, prospective, interventional study included critically ill adult patients undergoing RRT for whom a discontinuation attempt was decided by the physician in charge. FST (1 or 1.5, if exposed within 7 days, mg/kg of iv furosemide) was performed within 12 h of RRT liberation. We collected patients’ baseline characteristics, urine output (UO) and urine levels of urea and creatinine at the time of FST. Our primary outcome was the successful liberation from RRT within 72 h of FST. We computed FST’s sensitivity, specificity, positive and negative predictive values (PPV, NPV) as well as its area under the curve (AUC) for RRT liberation. Secondary outcomes were successful RRT liberation at ICU and hospital discharge as well as adverse events (AE) associated with FST.

Results: Among the 52 patients included in the study, FST was positive (UO ≥ 200 mL within 2 h of FST) in 12 (23.1%). Compared to those with a negative FST, these patients had similar baseline characteristics, but higher UO prior to RRT liberation (26 vs 235 mL/day, p < 0.001) and higher urinary urea level at the time of FST (47.1 vs 124.5 mmol/l, p < 0.001). FST’s performance for the primary outcome was: sensitivity 0.69, specificity 0.95, PPV 0.81, NPV 0.90 with a resulting AUC of 0.97. Its performance was lower to predict RRT liberation at ICU (AUC 0.67) and hospital discharge (AUC 0.58). There was no significant AE associated with FST.

Conclusions: FST has excellent performance to predict RRT liberation within 72 h with a high specificity and NPV.

Reference Chawla LS et al. Crit Care 2013;17:R207

P326 Effect of renal function on acidemia caused by hyperlactatemia in sepsis: interim analysis of an observational study

S Maitra, EE Ernest, H Mehrotra, S Bhattacharjee, DK Baidya

All India Institute of Medical Sciences, Anaesthesiology, Pain Medicine Critical Care, New Delhi, India

Critical Care 2026, 30 (Suppl 1): P326

Introduction: Renal response to compensatory decrease in PaCO 2 in response to metabolic acidosis is controversial. Preclinical data demonstrated that change in plasma bicarbonate in metabolic disorder is not contributed by the primary disorder itself, rather a maladaptive renal response. A previous study reported that acidosis from hyperlactatemia was modulated by renal dysfunction [1]. We hypothesized that acidosis caused by hyperlactatemia in sepsis patients is multifactorial and alone renal function cannot explain it.

Methods: Data of n = 38 patients with sepsis from perforation peritonitis with hyperlactatemia (arterial lactate > = 2 mEq/L) were analysed in this interim analysis. Effect of serum lactate level on standardized base deficit (sBD) was evaluated by Spearman correlation. Indirect effect was serum lactate on sBD was evaluated by generalized linear model (GLM) mediation analysis.

Results: Median (IQR) arterial lactate was 3.35 (2.60- 4.75) mEq/L and sBD was 9.5 (6.2- 13.7) mEq/L. There was a statistically significant correlation between sBD and arterial lactate (rho = 0.58, p < 0.001). However, there was no indirect effect of arterial lactate on sBD mediated by serum creatinine (beta = -0.009, p = 0.86). No indirect effect was observed with other buffers such as albumin ( p = 0.26) or haemoglobin ( p = 0.32). Multiple linear regression reported that serum lactate was an independent predictor of sBD even after adjustment for other buffers (t = 2.79, p = 0.009).

Conclusions: Our preliminary analysis suggests that acidosis caused by hyperlactatemia was not modulated by serum creatinine level. This study also suggests that acidosis multifactorial and lactate is one of the direct contributors to it. However, as this is an interim analysis from a small cohort, validation in the larger cohort is required.

Reference Gattinoni L et al. Am J Respir Crit Care Med 2019;200:582–589

P327 Effect of free water-based intervention on serum sodium and clinical outcomes in critically ill patients with moderate to severe hypernatremia: a target trial emulation

A Caroli, A Chaba, J Nübel

Austin Hospital, Department of Intensive Care, Melbourne, Australia

Critical Care 2026, 30 (Suppl 1): P327

Introduction: This study aimed to evaluate whether a free water deficit-based intervention (FWBI) accelerates hypernatremia correction and improves clinical outcomes in ICU patients. Moderate to severe hypernatremia is frequent among critically ill patients and is associated with poor outcomes, and the optimal correction strategy and its impact on clinically relevant endpoints remain unclear.

Methods: We conducted a target trial emulation using the MIMIC-IV database, including adult patients with moderate to severe hypernatremia (serum sodium ≥ 150 mmol/L). The intervention consisted of administering a volume of hypotonic fluids at least equal to the calculated free water deficit in the first 24 h. Patients were assigned to the FWBI or usual care group using cloning, censoring, and weighting to reduce immortal time and confounding biases. The primary outcome was resolution of hypernatremia within 24 h. Secondary outcomes included serum sodium change, ICU/hospital mortality, and ICU/hospital length of stay. Robustness was assessed using targeted minimum-loss based estimation and overlap propensity weighting.

Results: 3,035 patients were eligible for the target trial. FWBI significantly increased the rate of hypernatremia resolution at 24 h (51% vs. 19%; HR 3.24, 95%CI 2.63–3.83) (Figure). Serum sodium decreased more rapidly in the FWBI group (–3.3 mmol/L vs. control; 95%CI –3.96 to –2.70). Mortality did not differ significantly between groups, but FWBI was associated with significantly shorter ICU and hospital stay. The benefit was greatest in patients with ICU-acquired hypernatremia and under invasive mechanical ventilation.

Conclusions: A physiologically guided free water deficit-based intervention accelerates hypernatremia correction and reduces ICU and hospital stay without evidence of harm. These findings justify a randomised controlled trial to determine the impact of this strategy on patient-centred outcomes. Figure (abstract P327) Forest plots of primary, secondary and subgroup results. Estimates were estimated under three causal-inference frameworks: cloning-censoring-weighting, targeted minimum-loss based estimation, and overlap weighting. All analyses emulated a predefined target trial protocol with consistent eligibility, treatment strategies, and follow-up definitions, and were adjusted for baseline confounders using stabilized weights specific to each method

P328 Association of early magnesium sulfate use with 28-day mortality for sepsis patients: a target trial emulation

X Luo, FR Lin, T Huang, JZ Zhang, AQ Lao, ZF Yang

Sun Yatsen Memorial Hospital, Sun Yatsen University, Intensive Care Unit, Guangzhou, China

Critical Care 2026, 30 (Suppl 1): P328

Introduction: Magnesium supplementation is commonly administered in critically ill patients for a variety of indications. However, the effect of early magnesium sulfate to improve sepsis outcomes remains controversial. We aim to emulate a target trial evaluating the effect of early magnesium supplementation on 28-day mortality.

Methods: This target trial emulation study utilized data from the Medical Information Mart for Intensive Care-IV version 3.1 (MIMIC-IV v3.1) database. The study included adult patients diagnosed with sepsis who received magnesium sulfate supplementation within the first 24 h of intensive care unit (ICU) admission. The intervention was defined as early magnesium sulfate administration following sepsis onset, and the primary outcome was 28-day all-cause mortality. The primary analysis was conducted using the parametric g-formula. Sensitivity analysis was performed to evaluate the impact of delayed magnesium sulfate use on 28-day mortality, confirming the robustness of the primary findings. Subgroup analyses were carried out based on age, sex, Sequential Organ Failure Assessment (SOFA) score, Charlson Comorbidity Index, and magnesium status to examine potential variations across different patient populations.

Results: A total of 21,272 patients met the inclusion criteria, of whom 10,739 (50.5%) received magnesium sulfate. The estimated 28-day mortality was 14.23% (95% CI, 12.36% to 16.47%) in the early magnesium sulfate group and 34.00% (95% confidence interval [CI], 31.98% to 36.33%) in the no magnesium sulfate group, yielding a relative risk of 0.42 (95% CI, 0.39% to 0.44%) (Figure). Lower mortality was consistently observed across all evaluated subgroups, regardless of baseline serum magnesium status.

Conclusions: Early magnesium sulfate use was associated with significantly lower mortality among critically ill patients with sepsis. These findings should inform the design of future randomized controlled trials evaluating early magnesium sulfate supplementation in sepsis. Figure (abstract P328) Detailed process and results of early magnesium sulfate use with sepsis patients: a target trial emulation

P330 Management of hypocalcemia in adult critically ill patients: an international survey

M Tujunen 1 , H Kiiski 1 , P Sivapalan 2 , A Granholm 2 , MP Wise 3 , KL Ellekjær 2 , TS Meyhoff 2 , A Perner 2 , MH Møller 2 , J Hästbacka 1

1 Tampere University Hospital, Intensive Care Unit, Tampere, Finland, 2 Rigshospitalet, Copenhagen University Hospital, Department of Intensive Care, Copenhagen, Denmark, 3 University Hospital of Wales, General Adult Intensive Care Unit, Cardiff, UK

Critical Care 2026, 30 (Suppl 1): P330

Introduction: Hypocalcemia is common in critically ill patients and associated with adverse outcomes, but its optimal management is uncertain. We examined views about management of hypocalcemia and need for interventional trials among international intensivists. We hypothesized substantial practice variation.

Methods: We conducted an international online survey in the Collaboration for research in Intensive Care (CRIC) network using REDCap. The survey was distributed in fall 2025 across 17 countries and included 21 questions on ionized calcium (iCa) monitoring, treatment practices, indications, and views on a future RCT.

Results: We received 964 responses giving a response rate of 32%. Most respondents worked in mixed ICUs (77%) and 64% were intensive care specialists. 75% of respondents reported measuring iCa levels several times a day. Hypocalcemia was reported most often corrected “frequently” (39%), typically at an iCa threshold < 1.0 mmol/L (46%), and using bolus administration (60%), while 15% of respondents reported correcting it rarely (Figure). Expectations regarding benefits varied. The most common mandatory indication was impaired coagulation and active bleeding (79%) and the most frequently reported contraindication was tumor lysis syndrome (39%). Most respondents would randomize patients in an RCT comparing calcium correction with no correction (91%) or different thresholds (92%), and rated both designs as clinically important (median 6, IQR 5–7 on a scale from 1 to 9). “Any adult general ICU patient” was considered an eligible population by 57% of the respondents. Most respondents (85%) anticipated no major barriers to such a trial.

Conclusions: Most intensivists reported measuring iCa frequently in adult ICU patients, yet preferences for hypocalcemia correction in clinical practice varied considerably. Despite mixed expectations regarding benefit, there was strong support for a future RCT to evaluate management of hypocalcemia in ICU patients. Figure (abstract P330) Reported thresholds and frequency of calcium supplementation

P334 Hypophosphatemia as a biomarker of metabolic unreadiness for enhanced nutrition in the PICU: a secondary analysis of the PEPaNIC RCT

N Umman Serin 1 , I Vanhorebeek 1 , F Güiza 1 , L Mebis 1 , S Verbruggen 2 , K Joosten 2 , G Van den Berghe 1 , J Gunst 1

1 KU Leuven, Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, Leuven, Belgium, 2 Erasmus Medical Center, Sophia Children’s Hospital, Division of Pediatric Intensive Care Unit, Department of Neonatal and Pediatric ICU, Rotterdam, Netherlands

Critical Care 2026, 30 (Suppl 1): P334

Introduction: The PEPaNIC RCT showed that early supplementation of insufficient enteral nutrition by parenteral nutrition (early-PN) worsened outcome of critically ill children as compared with omitting PN for 1 week (late-PN). The best timing to initiate nutritional support in the pediatric intensive care unit (PICU) remains unclear. In adults, declining phosphate levels may identify patients who are particularly harmed by early-PN. We assessed whether early hypophosphatemia (hypoP) in critically ill children may indicate metabolic intolerance to nutrition.

Methods: This PEPaNIC secondary analysis investigated whether development of hypoP statistically interacts with the randomized intervention for its impact on outcome (new infections, duration of PICU dependency, 90-day mortality, and duration of mechanical ventilation and hospital stay), adjusting for baseline risk factors. Subsequently, the impact of early-PN vs late-PN in patients with and without early hypoP was assessed. Analyses were performed for phosphate abnormalities on PICU day 1 and 2, with and without imputing missing phosphate data.

Results: Of patients with available phosphate measurements, 19.9% and 27.5% developed hypoP on day 1 and 2, respectively. Day 1 hypoP did not interact with the randomized intervention for any outcome. On day 2, hypoP interacted with randomization for risk of new infection ( p = 0.03), likelihood of earlier live PICU discharge ( p = 0.03) and time to live weaning from mechanical ventilation ( p = 0.02). Harm by early-PN was more pronounced in patients with hypoP than in those without. After imputing missing phosphate data an additional interaction was found for 90-day mortality ( p = 0.03) revealing higher mortality with early-PN in patients with hypoP.

Conclusions: Development of hypoP may identify critically ill children who are particularly harmed by early-PN. This opens perspectives for its use as biomarker of unreadiness for enhanced nutrition, which requires further investigation.

P337 Restricted caloric strategy during refeeding hypophosphatemia and its impact on mortality in the ICU

A Chaba 1 , K White 2

1 Pitié Salpêtrière Assistance Publique des Hopitaux de Paris, Intensive Care Unit, Paris, France, 2 Princess Alexandra Hospital, Intensive Care Unit, Woolloongabba, Queensland, Australia

Critical Care 2026, 30 (Suppl 1): P337

Introduction: Refeeding hypophosphatemia is a common complication in critically ill patients and has been independently associated with worse outcomes. Whether a restrictive caloric strategy in this setting improves survival remains uncertain.

Methods: We conducted a target trial emulation using routinely collected data from six intensive care units in Queensland, Australia. Adult patients who developed moderate to severe hypophosphatemia (decrease in serum phosphate > 0.16 mmol/L and a serum phosphate level less than 0.65 mmol/L) within 24 h of initiating artificial nutrition were eligible. Patients were assigned to a restrictive caloric strategy (decreased caloric intake on the day hypophosphatemia occurred) or usual care (increased caloric intake permitted). The primary outcome was 30-day hospital mortality. Cloning, censoring, and weighting were used to minimize immortal time bias, and robustness was assessed with targeted minimum-loss based estimation and overlap propensity score weighting.

Results: Among 1,304 eligible patients. The mean age was 55 ± 17 years, 59% were male, and the mean APACHE II score was 20 ± 7. At 24 h, caloric intake decreased by 5.4 kcal per kilogram per day in the intervention group and increased by 12 kcal per kilogram per day in the control group. Thirty-day hospital mortality was 9% with the restrictive strategy and 18% with usual care (RR, 0.47; 95% CI, 0.32 to 0.69) (Figure). Restrictive feeding was also associated with lower ICU mortality, reduced persistent critical illness, and shorter ICU and hospital stays. Phosphate trajectories were similar between groups.

Conclusions: In this target trial emulation, a restrictive caloric strategy in patients with refeeding hypophosphatemia was associated with lower mortality and improved clinical outcomes, independent of phosphate correction. These findings support further randomized controlled trials to confirm the role of restrictive feeding in this high-risk ICU population. Figure (abstract P337) Estimated 30-day hospital mortality risk under the restricted caloric treatment strategy versus usual care

P339 Reducing the rate of enteral feeding interruption of patients on mechanical ventilation in intensive care unit by a Lean Six-Sigma approach

X Nie 1 , X Li 1 , X Zheng 1 , X Liu 1 , J Jin 1 , Wm Chan 2

1 The University of Hong Kong Shenzhen Hospital, Department of Adult Intensive Care, Shenzhen, China, 2 LKS Faculty of Medicine, The University of Hong Kong, Critical Care Medicine Unit, Hong Kong, SAR China

Critical Care 2026, 30 (Suppl 1): P339

Introduction: Interruption of enteral feeding is common for patients on mechanical ventilation [1].

Methods: A Lean Six-Sigma approach was used to define the problem, identify the root causes, and design an approach to minimize interruption. These include a pragmatic protocol to streamline enteral tube feeding, an evidence based approach of feeding tubes care, together with adopting a portable direct vision naso-jejunal (PDV-NJ) tube insertion system. The PDV-NJ tube insertion system is a novel device with a video camera at the tip of the naso-jejunal tube (NJT). Insertion was done at bedside by ICU nurses. Successful placement was confirmed by visualizing important landmarks until jejunal villi were identified (Figure). Patients at high risk of failed naso-gastric feeding were also identified and early switch to NJT feeding was arranged. The aim is to achieve enteral feeding targets within 48 h of ICU admission. The Enteral Feeding Interruption (EFI) Rate was defined as the number of patients having interruption for over 60 min per day relative to the total number of ventilated patients on enteral feeding.

Results: The programme was conducted from Aug 24 to May 25, with 98% of ICU Nurses became familiar with the care of NJT. ICU staff satisfaction rate with the PDV-NJ system was 93%. A total of 268 PDV-NJ tubes were inserted. Success rate of post-pyloric placement at first attempt was 90.74%. The mean insertion time was 18.6 min (SD 8.67 min). Using the period from Oct 23 to Jul 24 as baseline, EFI rate dropped from 58.45% to 19.48%. There was no unplanned NJT removal due to blockage.

Conclusions: A protocol using the Lean Six-Sigma approach can effectively reduce feeding interruptions for patients on mechanical ventilation.

Reference Yu K et al. Chinese Medical Journal 2022;135:1814–1820

Figure (abstract P339) View from portable direct vision naso-jejunal (PDV-NJ) tube insertion system

P341 Oxygen consumption and muscular evaluation of standardized ICU rehabilitation exercises in healthy population

A Bisman 1 , G Cuvelier 1 , S Leteneur 2 , S Mashayekhi 3 , M Cotils 4 , L Dujardin 1 , B Delhaye 1 , C Bousseau 1 , F Duprez 5 , CE Hickmann 5

1 Laboratoire de l´Effort et du Mouvement, HEPH Condorcet, Tournai, Belgium, 2 LAMIH, Université Polytechnique Hauts de France UPHF, LAMIH, Valenciennes, France, 3 Service des Soins Intensifs, Centre Hospitalier EpiCURA, Hornu, Belgium, 4 Service de Pneumologie, Centre Hospitalier EpiCURA, Hornu, Belgium, 5 Unité de Recherche et d’Innovation Condor EpiCURA URICE, Soins Intensifs, Hornu, Belgium

Critical Care 2026, 30 (Suppl 1): P341

Introduction: The objective of this preliminary study was to explore the feasibility of measuring oxygen consumption (VO2) coupled with muscle recruitment assessment during a standardized exercise program in healthy subjects. This methodology is intended to be transposed and compared to critical and post-intensive care unit (ICU) patients. Early physical activity is considered a feasible and safe approach to prevent or treat neuromuscular complications in ICU, but current "early mobilization" lacks standardization in intensity and duration [1].

Methods: Twenty healthy adults (13 women, 7 men; mean age ± SD: 32 ± 8 years) were included. The protocol consisted of 10 standardized exercises: five for the upper limbs (UL), from 1 to 5 and five for the lower limbs (LL), from 6 to 10. Each exercise lasted three minutes, followed by two minutes of rest. Continuous VO2 was measured using indirect calorimetry (QNR-G + , Cosmed©) and expressed as a percentage of the strict rest value. Surface electromyography (sEMG) was recorded on the biceps brachii (BB), rectus femoris (DF), and tibialis anterior (TA), expressed as a percentage of maximal voluntary contraction.

Results: Increases in were observed during all UL exercises, ranging from to (mean ± SD: 14 ± 18% to 117 ± 41% ( p < 0.001)). Similar increases were observed during LL exercises, ranging from to (27 ± 23% to 174 ± 64% ( p < 0.001)). The most significant muscle recruitment was observed for the BB during UL exercises 1, 2, 4, and 5; for the DF during LL exercises 6, 7, 8, 9, and 10; and for the TA during exercises 6 and 9.

Conclusions: These preliminary data demonstrate the potential of indirect calorimetry to quantify the intensity of exercises administered to patients in rehabilitation and suggest the feasibility of segmental analysis via sEMG.

Reference Eggmann S et al. Intensive Care Med 2025;51:2199–2212

P342 The effect of augmented protein intake on nitrogen balance: a nested cohort of the TARGET Protein trial

AC Chaba

Pitié Salpêtrière Assistance Publique des Hopitaux de Paris, Intensive Care Unit, Paris, France

Critical Care 2026, 30 (Suppl 1): P342

Introduction: The impact of augmenting enteral protein intake on nitrogen balance and urea generation in critically ill patients is poorly understood. We aimed to investigate the impact of augmenting protein intake on nitrogen balance and urea generation in a nested cohort within the TARGET Protein trial.

Methods: We conducted a single-center study within a cluster randomized cross-over trial. Consecutive patients were enrolled during either the standard protein intake period (n = 52) or the augmented protein intake period (n = 55). Nitrogen balance, its components, and plasma urea concentrations were compared between groups. Multivariable analysis identified factors independently associated with nitrogen balance.

Results: From day 1 to day 7 the mean protein intake achieved was 0.84 ± 0.73 g/kg per day in the control group versus 1.35 ± 0.94 g/kg per day in the augmented protein group. Patients receiving augmented protein achieved a less negative nitrogen balance than those receiving usual protein (mean difference + 5 g/day; 95% CI, 0.4 to 10; p = 0.033), driven by greater nitrogen intake (mean difference + 7 g/day; 95% CI, 5 to 10; p < 0.001). Independent predictors of nitrogen balance were ideal body weight (–0.18 g per kg; 95% CI, –0.35 to –0.01; p = 0.040), acute kidney injury at ICU admission (+ 4.7 g; 95% CI, 0.10 to 9.3; p = 0.046), and allocation to augmented protein therapy (+ 5.1 g; 95% CI, 0.43 to 9.7; p = 0.033). From day 1 to day 7, plasma urea concentrations were greater increased more in the augmented protein group (median 14 vs. 11 mmol/L) (Figure), with greater urea nitrogen accumulation (+ 3 g; 95% CI, 1.0 to 6.0; p = 0.035). Approximately 60% of the additional positive nitrogen balance was accounted for by urea generation.

Conclusions: Augmented protein intake increased nitrogen balance in critically ill patients but also urea production and plasma urea concentration, suggesting limited usefulness. Figure (abstract P342) Blood urea evolution after enteral feeding start

P343 Early protein goal intake and mortality in septic patients

L Velasco, OI Aguilera Olvera, JA Villalobos Silva, GA Aguirre Gomez, M Rodriguez Reyna, LC Gaucin Delgado

High Specialty Regional Hospital of Victoria, Intensive Care Unit, Ciudad Victoria, Mexico

Critical Care 2026, 30 (Suppl 1): P343

Introduction: Current guidelines recommend achieving full protein goal intake past 72 h in critically ill patient [1]. Aim to evaluate early protein goal intake in septic shock patients and mortality.

Methods: This retrospective study included septic ICU patients in a tertiary center in Mexico, excluding those under 18 years and pregnant women. Patients were grouped according to whether they reached 1.3 g/kg/day of protein within 48 h. Numerical and categorical data were summarized using means (SD) and percentages, and associations were assessed with odds ratios and the chi-square test ( p < 0.05).

Results: We analyzed 38 patients, 63% female, with a mean age of 50 years. Type 2 diabetes (42%) and hypertension (50%) were the most common comorbidities, and abdominal infections were the main source (45%). Mean APACHE II and SOFA scores were 15.9 and 8.3. Septic shock occurred in 79%, and 76% had positive cultures. Early nutrition was provided in 95% of cases, mainly enteral, with 71% experiencing minor gastrointestinal complications. Mortality was 26%, and 29% required renal replacement therapy. Nutrition began on day 1, and protein goals were met by day 1.7. Early protein goal achievement was not associated with mortality (OR 1.97; p = 0.41) (Figure).

Conclusions: In this small retrospective study, early protein intake (< 48 h) was not associated with mortality. Although gastrointestinal symptoms were common, no complications were attributable to early nutrition. Further studies are needed to clarify the role of early protein intake in critically ill patients. Figure (abstract P343) Relationship between protein intake, survival, and mortality

Reference Singer et al. Clin Nutr 2023;42:1671–1689

P344 Impact of impaired intestinal absorption in mechanically ventilated patients on feeding efficiency—preliminary data from the ATTAINMENT study

C Cobilinschi 1 , AC Andrei 1 , A Dumitriu 1 , R Darie 1 , R Tincu 1 , I Marandiuc 2 , B Velescu 3 , E Moisa 4 , L Mirea 1

1 Clinical Emergency Hospital of Bucharest, Anaesthesia and Intensive Care, Bucharest, Romania, 2 Cantacuzino National Institute for Medical Military Research and Development, Toxicology Department, Bucharest, Romania, 3 Carol Davila University of Medicine and Pharmacy, Anaesthesia and Intensive Care, Bucharest, Romania, 4 Elias Clinical Emergency Hospital, Anaesthesia and Intensive Care, Bucharest, Romania

Critical Care 2026, 30 (Suppl 1): P344

Introduction: Prolonged negative energy balance in the ICU is an independent mortality risk factor. Gastrointestinal(GI) dysfunction is common and may limit feeding efficiency, but the true rate of malabsorption in mechanically ventilated ICU patients remains uncertain. This study investigates whether tailored nutritional support enables adequate energy and protein delivery in ICU patients with documented GI dysfunction ( NCT06510348 ).

Methods: This randomized trial includes mechanically ventilated patients with controlled shock. Eligibility requires GI dysfunction, defined by increased gastric residual volume on ultrasound and impaired paracetamol absorption after a 15 mg/kg test dose. Patients are randomized to enteral nutrition (EN) or supplemental parenteral nutrition (SPN).In the EN group, feeding is advanced to 75% of target by day 5 and to full intake thereafter. In the SPN group, SPN is initiated to reach 75% of target by day 5,with trophic EN providing the remaining 25%. Primary outcomes are cumulated energy and protein balances on days 10 and 15.Two-way ANOVA was used to assess differences in daily energy and protein intake per kg of actual body weight.

Results: Out of 1,128 patients admitted during 2025, 327 required mechanical ventilation for more than 72 h. Among these 327 patients, 85 fulfilled the predefined inclusion criteria, and 31 of them (36%) had confirmed malabsorption. The SPN group achieved higher energy delivery on days 5 and 6, while from day 7 onward both groups reached similar energy intake. Protein intake was consistently higher in the SPN group, however the recommended 1.2 g/kg/day target was reached only on day 10.

Conclusions: In this cohort of ICU patients with GI dysfunction, SPN allowed earlier achievement of energy and protein targets without evidence of overfeeding. The study also provides prospective comparative data on ultrasound-estimated gastric residual volume and the paracetamol absorption test, showing that the two methods offer complementary information for identifying impaired GI function.

P345 Resting energy expenditure assessment in critically ill patients: direct vs. predictive measurement on the 3rd day of hospitalization

C Ferreira 1 , B Rachão 2 , M Santos Silva 3 , F Cardoso 3 , C Teixeira 3

1 ULS São João, Serviço de Medicina Intensiva, Porto, Portugal, 2 ULS São João, Porto, Portugal, 3 ULS São João, Unidade Local de Saúde São João, Porto, Portugal

Critical Care 2026, 30 (Suppl 1): P345

Introduction: Accurate determination of the energy requirements (ER) of critically ill patient (CIP) is essential to ensure adequate nutritional support [1]. Indirect calorimetry (IC) is the reference method, but its clinical use is limited and often replaced by predictive equations (PE) or international society recommendations (ISR) [2]. The reliability of these approaches throughout hospitalization remains poorly explored [3]. This study aimed to assess resting energy expenditure (REE) by IC on the 3rd day of hospitalization and compare it with values estimated by predictive equations (PE) and international society recommendations (ISR).

Methods: Cross-sectional observational study with 30 patients admitted to the Intensive Care Medicine Department of the Local Health Unit of São João. ER were assessed by IC, PEs (Harris–Benedict, Penn State, Ireton Jones, Swinamer and Faisy) and ISRs (ESPEN, ASPEN and BRASPEN). Non-parametric statistical tests were applied ( p < 0.05).

Results: The sample included 63.3% men, with a mean age of 62 ± 15 years (23–86), mean stay of 23 days and mortality 20%. Overweigh/obesity prevalence was 53.3%. Median REE by IC was 17 kcal/kg (P25 = 14, P75 = 20). All PEs and ISRs showed significant positive correlations with IC ( p < 0.01), with Harris–Benedict and Swinamer showing the highest correlation coefficients (rs = 0.778). BRASPEN was the closest to IC (18 kcal/kg, p = 0.314). ASPEN underestimated ER with a median of 14 kcal/kg, p < 0.001. All remaining PEs and ISRs significantly overestimated ER ( p < 0.001). Men had higher IC values ( p = 0.001). Age correlated negatively with IC ( p = 0.011). Median exclusive intake was 11 kcal/kg/day, significantly lower than IC ( p = 0.011).

Conclusions: Important discrepancies were found between PEs/ISRs and IC, reinforcing the value of this gold-standard method and suggesting early underfeeding.

References Oami T et al. Nutrients 2025;17:1352 Singer et al. Clin Nutr 2023;42:1671–89 Sordi AF et al. Clin Nutr ESPEN 2022;51:239–45

P346 Interpersonal and communication skills of the intensive care unit dietitian in facilitating personalized nutritional care

L De Hart 1 , E Dom 1 , C Verhelst 1 , L Leemans 1 , R Blaauw 2 , E De Waele 1

1 UZBrussel, Clinical Nutrition and Dietetics, Brussel, Belgium, 2 Stellenbosch University, Division of Human Nutrition, Faculty of Medicine and Health Sciences, Cape Town, South Africa

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Introduction: The role of the intensive care unit (ICU) dietitian (RD) has expanded to include active participation in multidisciplinary decision-making. Effective interpersonal and communication skills support collaboration with the multi-professional team (MPT) and may improve consistent implementation of nutritional protocols and individualized nutrition care plans. Existing literature suggests that interprofessional communication is a crucial factor in overcoming barriers to adequate nutritional support in the ICU [1–3].

Methods: We conducted a descriptive review of the literature to identify interpersonal and communication skills relevant to the ICU RD.

Results: Key interpersonal and communication skills identified include clear and respectful verbal communication, clarification of nutrition-related orders, conflict resolution, advocacy for timely nutrition delivery, culturally appropriate communication. Non-verbal skills include active listening, showing empathy, effective problem-solving and a professional personal appearance. These skills support effective collaboration with ICU physicians, nursing staff, speech therapists, logistics department and foodservice teams, as well as other allied health professionals involved in nutrition delivery.

Conclusions: The ICU RD´s interpersonal and communication skills are important facilitators in supporting the MPT’s adherence to nutrition protocols as well as an individualized nutrition plan and ensuring continuity of nutritional care for critically ill patients.

References Derouin E et al. Clin Nutr ESPEN 2021;45:245–251 Zaher S et al. Front Nutr 2025;12:1675530 Alsamani AS et al. Saudi Journal Of Health Systems Research 2023;3:1–9

P348 Metabolomic endotyping of an international observational sepsis cohort

J Brandsma 1 , JG Chenoweth 2 , JW Thompson 3 , G Oduro 4 , T Vantha 5 , N Adams 6 , EL Tsalik 3 , CW Woods 3 , DV Clark 2

1 Henry M. Jackson Foundation, Austere Environments Consortium for Enhanced Sepsis Outcomes, Hesda, USA, 2 Henry M. Jackson Foundation, Hesda, USA, 3 Duke University, School of Medicine, Durham, NC, USA, 4 Komfo Anokye Teaching Hospital, Kumasi, Ghana, 5 Takeo Provincial Referral Hospital, Takeo, Cambodia, 6 Infectious Diseases Directorate, Naval Medical Research Command, Silver Spring, MD, USA

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Introduction: Expeditious and accurate information is critical for clinical decision-making in sepsis and can be enhanced using host-response biomarkers indicative of sepsis subtype and prognosis. Our research consortium has previously identified clinically relevant sepsis endotypes based on gene and inflammatory protein expression levels, and we now expand upon those results by integrating metabolomics data from matched samples.

Methods: Sepsis patients were recruited at clinical sites in Cambodia, Ghana and the USA (n = 540), and concentrations of 150 endogenous blood plasma metabolites were quantified using the Biocrates AbsoluteIDQ p180 protocol. Patients were assigned to one of five previously identified sepsis gene expression endotypes, and metabolite profiles were compared between groups, as well as between 28-day survivors and non-survivors.

Results: Distinct clusters of metabolites were associated with each of the sepsis endotypes, and could be linked to significant differences in disease prognosis and clinical presentation. Patients with a low-risk endotype had a plasma lipidome closest to that of non-diseased adults. In contrast, patients with a high-risk endotype showed significantly elevated short-chain acylcarnitine and decreased sphingomyelin levels, as well as a highly skewed lyso-to-diacylphosphatidylcholine ratio. Furthermore, sepsis non-survivors showed more pronounced deviations and endotype-specific differences in metabolite expression levels than sepsis survivors.

Conclusions: Sepsis patients with different disease endotypes differ markedly in the composition of their circulating metabolome. These results provide evidence for distinct pathways of host metabolic dysregulation and organ disfunction, and warrant further study into immunometabolic regulation of sepsis.

P349 Admission plasma lactate-to-glucose ratio predicts 90-day mortality but not metformin response in type 2 diabetic patients with sepsis

SJ Noorloos 1 , J Minturn 1 , IE Saraiva 1 , D Payen 2 , H Gómez 1

1 University of Pittsburgh, Department of Critical Care Medicine, Pittsburgh, USA, 2 Université Paris Cité Sorbonne, Paris, France

Critical Care 2026, 30 (Suppl 1): P349

Introduction: A high lactate to glucose (L/G) ratio may reflect the presence of metabolic reprogramming away from oxidative phosphorylation, a potential mechanism of sepsis-induced organ dysfunction. In this study we tested the hypotheses that (1) a high L/G ratio is associated with worst clinical outcomes in patients with type 2 Diabetes Mellitus (DM2) and sepsis, and (2) a high L/G ratio can identify patients that will have the highest impact of metformin on mortality.

Methods: We conducted a retrospective cohort study of critically ill DM2 patients with sepsis admitted to one of the 16 University of Pittsburgh Medical Center (UPMC) hospitals, with available ICU admission plasma lactate and glucose. Associations between L/G ratio and 90-day mortality were examined using Kaplan–Meier curves and Cox-proportional hazards modeling, while stage 2–3 AKI was investigated using multivariable logistic regression models. We classified patients into low or high L/G ratio based on the Youden index and investigated the association of L/G ratio with outcome and impact of the use of metformin on 90-day mortality.

Results: Among 14,847 patients, 4,309 had an available L/G ratio, of whom 168 received metformin. The L/G ratio was associated with 90-day mortality (HR 1.49, 95%CI 1.38–1.61, p < 0.001), but not with the development of stage 2–3 AKI (OR 1.14, 95%CI 0.8–1.9). The Youden threshold (0.168) classified 2,402 patients as low and 1,907 as high L/G ratio. A high ratio was associated with increased 90-day mortality (OR 1.38, 95%CI 1.23–1.54, p < 0.001), but not with stage 2–3 AKI compared to low L/G ratio (OR 1.13, 95%CI 0.93–1.38). Metformin exposure was associated with lower 90-day mortality in both groups (Figure).

Conclusions: A high ICU admission L/G ratio is associated with higher 90-day mortality in septic DM2 patients. While metformin was associated with improved survival overall, the L/G ratio did not predict which patients would respond to therapy.

Figure (abstract P349) Kaplan–Meier curves for 90-day survival stratified by metformin use within low and high lactate-to-glucose (L/G) ratio groups

P350 Metabolic reprogramming of glycolysis in ECMO patients: identification of prognostic biomarkers through transcriptomic and machine learning approaches

S Chen, L Liu, H Xue, D Hu, Y Zhu, J Wu, H Fu, Y Yang, H Qiu, S Liu

Zhongda Hospital, School of Medicine, Southeast University, Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Trauma Center, Nanjing, China

Critical Care 2026, 30 (Suppl 1): P350

Introduction: Extracorporeal membrane oxygenation (ECMO) is a critical therapy for patients with severe cardiopulmonary failure, but outcomes are variable and reliable prognostic biomarkers are lacking. Glycolysis plays a key role in cellular metabolism and stress responses. This study explores the differential expression and prognostic potential of glycolysis-related genes in ECMO patients.

Methods: Transcriptomic data from ECMO patients were analyzed to identify differentially expressed glycolysis-related genes between success and failure groups. Bioinformatics analyses included volcano plots, chromosomal distribution, heatmaps, and correlation networks. Functional implications were assessed using Gene Ontology (GO), KEGG, and Gene Set Enrichment Analysis (GSEA). Machine learning methods such as LASSO regression and SVM-RFE were used to identify key prognostic biomarkers, and predictive performance was evaluated through ROC curves, calibration plots, and decision curve analysis (DCA).

Results: Multiple glycolysis-related genes were differentially expressed between ECMO success and failure groups. Enrichment analysis revealed their involvement in metabolic reprogramming, apoptosis, inflammation, and hypoxia. Core genes like ALDOB, FKBP4, IGFBP3, and ALDH3A1 were identified as robust prognostic biomarkers. ROC analysis demonstrated high discriminatory ability (AUC > 0.95 in both training and validation sets). A combined risk model improved predictive accuracy, confirmed by DCA and calibration analyses.

Conclusions: Glycolysis-related gene signatures are closely associated with ECMO outcomes. These biomarkers and the predictive model provide insights into metabolic regulation during ECMO and may serve as tools for risk stratification and personalized management of critically ill patients.

P351 U-shaped association between stress hyperglycemia ratio and mortality in AHRF: validation through consensus clustering and supervised machine learning models

F Mingxing 1 , Z Qi 2 , Z Linru 2

1 Hebei Medical University Third Hospital, Intensive Care Unit, China, 2 Hebei Medical University Third Hospital, China

Critical Care 2026, 30 (Suppl 1): P351

Introduction: Acute hypoxemic respiratory failure (AHRF), a life-threatening condition in critically ill patients, correlates with poor clinical outcomes. Although stress hyperglycemia ratio(SHR) is implicated in critical illness severity, its prognostic role in AHRF remains undefined. This study investigates the association between SHR and mortality risk in AHRF patients.

Methods: We retrospectively analyzed 2514 AHRF patients from the MIMIC-IV database. Restricted cubic splines identified optimal SHR thresholds. Kaplan–Meier survival analysis and Cox proportional hazards models evaluated 28-day mortality. Machine learning techniques (Boruta feature selection, CoxBoost + SuperPC modeling) assessed SHR’s predictive utility. Consensus clustering stratified patients into phenotypes based on clinical profiles.

Results: Higher SHR was associated with progressively increased 28-day, in-hospital, and overall mortality (Figure). Patients in the highest SHR quartile had significantly greater 28-day mortality (HR 3.89, 95% CI 2.81–5.40). Restricted cubic splines demonstrated a U-shaped relationship, with an inflection at 0.929. SHR was the most important predictor in Boruta analysis. The CoxBoost + SuperPC model showed the highest discriminative performance (C-index 0.836). Consensus clustering revealed three phenotypes: Phenotype I (metabolically stable, mild inflammation; mortality 2.7%), Phenotype II (moderate inflammation with metabolic imbalance; mortality 24%), and Phenotype III (hyperinflammation with metabolic dysfunction and hypoxia; mortality 30%). SHR ≥ 0.93 was most strongly associated with mortality in Phenotype II.

Conclusions: A U-shaped association between SHR and 28-day mortality in AHRF, with the highest quartile SHR linked to a 3.89-fold mortality risk. Consensus clustering identified three phenotypes, where Phenotype-III(high inflammation-metabolic dysfunction) exhibited the highest mortality, and SHR specifically stratified mortality risk in Phenotype-II.

Figure (abstract P351) A. Patient inclusion; B. Boruta feature selection; C. Predictive models constructed using the LOOCV Framework and 28-day Kaplan–Meier survival curve in Train dataset; D. Characteristics of the phenotypes and Kaplan–Meier survival curves illustrating the survival probability for AHRF patients grouped by a SHR cut off of 0.93 among the three phenotypes; E. Study flow chart

P352 Acute and long-term impact of tight versus liberal blood glucose control in corticosteroid-treated critically ill patients

E Vanderwegen 1 , I Vanhorebeek 1 , F Güiza 2 , DD Benoit 3 , E Hoste 3 , A Wilmer 4 , B Stessel 5 , J Dubois 5 , G Van den Berghe 2 , J Gunst 2

1 KU Leuven, Laboratory of Intensive Care Medicine, Leuven, Belgium, 2 KU Leuven, Clinical Division and Laboratory of Intensive Care Medicine, Leuven, Belgium, 3 UGent, Department of Intensive Care Medicine, Gent, Belgium, 4 KU Leuven, Medical and Laboratory Intensive Care Unit, Leuven, Belgium, 5 Jessa Hospital, Department of Anesthesiology and Intensive Care Medicine, Hasselt, Belgium

Critical Care 2026, 30 (Suppl 1): P352

Introduction: Iatrogenic severe hyperglycemia by early parenteral nutrition (PN) was shown harmful in critical illness. We hypothesized that corticosteroids in ICU are another iatrogenic cause of severe hyperglycemia, increasing vulnerability for its acute and long-term harmful effects.

Methods: The hypothesis was tested in a secondary analysis of the multicenter TGC-Fast trial, in which patients not receiving early PN were randomized to tight (TGC) or liberal (LGC) glucose control [1]. We assessed whether baseline corticosteroids, defined as systemic corticosteroids initiated on ICU d-1 or 2, statistically interacted with randomization for impact on acute and 2-year outcomes via multivariable regression. The effect of TGC vs LGC was reported for patients with and without baseline corticosteroids, unadjusted and adjusted for baseline risk factors. p < 0.05 and interaction- p < 0.1 were considered significant.

Results: Of 9230 randomized patients, 2293 (24.8%) received baseline corticosteroids. Patients with baseline corticosteroids had higher blood glucose concentrations and insulin needs than patients without corticosteroids. There was significant interaction between baseline corticosteroids and randomization to TGC vs LGC on occurrence of in-ICU delirium, reduced from 33.1% to 27.5% in the first week ( p = 0.005) with TGC for patients on corticosteroids only. At 2-year follow-up, significant interaction was present for mortality and mental health outcomes. For patients on corticosteroids only, TGC reduced 2-year mortality from 32.8% to 28.7% ( p = 0.03), improved SF-36 mental component scores from 44.5 ± 12.8 to 46.0 ± 12.8 ( p = 0.02), and improved subscores for vitality ( p = 0.03) and mental health ( p = 0.03). Similar results were obtained after adjustment for baseline risk factors.

Conclusions: Corticosteroids in ICU increased the severity of hyperglycemia and TGC in corticosteroid-treated patients reduced in-ICU delirium and improved long-term survival and mental health outcomes.

Reference Gunst J et al. N Engl J Med 2023; 389:1180–1190

P353 Intraoperative glycaemic variability and postoperative infections after elective and urgent coronary artery surgery: a Netherlands heart registration analysis

G Mondelli 1 , TC Rettig 2 , S Houterman 3 , PG Noordzij 1

1 St. Antonius Hospital, Anaesthesiology, Intensive Care and Pain Medicine, Utrecht, Netherlands, 2 Amphia Hospital, Department of Anaesthesiology and Intensive Care, Breda, Netherlands, 3 Netherlands Heart Registration, Utrecht, Netherlands

Critical Care 2026, 30 (Suppl 1): P353

Introduction: This study evaluates whether intraoperative glycaemic variability (IGV) is associated with postoperative infections in a large national cardiac surgery registry, and explores whether this relationship differs in patients with a history of diabetes. IGV may be associated with adverse events after cardiac surgery, including postoperative infections. Pre-existing diabetes may increase the extent of IGV, but most previous studies are small or single centre cohorts.

Methods: A nationwide cohort study that included all adult patients undergoing isolated CABG from the Netherlands Heart Registration between January 2019—June 2024. IGV was defined as the difference between the highest and the lowest intraoperative serum glucose concentration. Multivariable logistic regression analysis adjusted for confounders was performed to investigate the association with postoperative infections after 30 days, including pneumonia, deep sternal wound infection, urinary tract infection and wound infection of the graft harvest site. An interaction term between IGV and diabetes was then added to the model to explore whether the relationship is affected by diabetes status.

Results: A total of 10,308 patients were included. The median IGV was 1.20 (IQR 0.30–2.50) mmol/L and 28.7% had diabetes. 341 patients (3.30%) developed a postoperative infection. Higher IGV was associated with an increased odds of 30-day postoperative infection (adjusted OR 1.08; 95% CI 1.03–1.15; p < 0.01). The interaction term was not significant ( p = 0.08), indicating no strong evidence for a differential effect by diabetes status.

Conclusions: Intraoperative GV shows a modest association with postoperative infections in adults undergoing elective and urgent isolated CABG. We found no clear evidence that this association differs in patients with diabetes. These results provide a foundation for further research on IGV, an easily modifiable factor, and its relationship to postoperative infections.

P354 Experience in a Mexican population with high-dose insulin infusion therapy in severe diabetic ketoacidosis (DKA) compared with standard therapy

YL Medina Osorio, E Mendoza Arteaga, S Maldonado Valencia, L Godinez Monroy, J Villalobos Silva

Public Health, Norberto Treviño Hospital, ICU, Ciudad Victoria, Mexico

Critical Care 2026, 30 (Suppl 1): P354

Introduction: DKA is a severe condition often requiring ICU care. Standard treatment uses crystalloids and insulin 0.1 U/kg/h, but higher doses may be needed in severe or shock cases to hasten ketone clearance, correct acidosis, and improve early metabolic recovery [1].

Methods: Retrospective review (2023–2025) identified 73 adults with severe DKA. Patients were grouped by 24-h insulin dose: high-dose ICU (≥ 0.10 U/kg/h) vs conventional IMCU (0.05–0.10). Demographic, metabolic data, insulin use, fluids, and outcomes were compared with t-test and Chi-square.

Results: A total of 250 records were reviewed; 73 patients (29%) with severe DKA were included. They were divided into two groups: ICU (intensive unit) and IMCU (intermediate unit). The mean age was 38 ± 13.2 UCI vs. 45 ± 19.1 IMCU, male 60% UCI vs 40% IMCU; BMI 25 ± 6.2 UCI vs 25 ± 6.4 IMCU; initial blood glucose levels 430.9 ± 150 mg/dL UCI vs 471 ± 170 mg/dL IMCU; admission pH: 6.92 ± 0.28UCI vs 7.13 ± 0.18 IMCU p < 0.05 (Figure); ketone levels 254.62 ± 91.27 mg/dL UCI vs 210 ± 89.79 mg/dL IMCU p; insulin infusion 24 h (UI) 187.4 ± 72 UCI vs 62.1 ± 24 IMCU p < 0.00; initial lactate levels 2.52 ± 3.75 UCI vs 2.23 ± 3.74 IMCU; insulin (UI) U/kg/hr: 0.13 ± 0.12 UCI vs. 0.05 ± 0.08 IMCU p < 0.00. Discharge glucose 170 ± 46 mg/dL UCI vs 165 ± 66 mg/dL IMCU; discharge pH 7.38 ± 0.06 UCI vs. 7.39 ± 0.06 IMCU; discharge time hours 16.48 ± 7.9 UCI vs 16.65 ± 5.1 IMCU. Inhibition of ketogenesis first 24 h: 64% UCI vs 70% IMCU. Total reanimation 3526.7 ± 1650 mL UCI vs 3968 ± 1440 mL IMCU p < 0.05. Acute kidney injury occurred in 34% of patients, and overall mortality was 7%.

Conclusions: In this Mexican cohort of severe DKA, ICU patients treated with high-dose insulin arrived with more profound acidosis, yet both groups achieved similar metabolic correction at discharge. IMCU patients required greater fluid resuscitation. These results suggest high-dose insulin is safe and effective when early intensive management is applied.

Reference Jozwiak M et al. Crit Care 2024;28:408

Figure (abstract P354) Box plot comparing admission pH between the two groups: intermediate care unit and ICU. The population pyramid shows a significant disparity in the choice of solutions administered between the two care groups. The box plot compares the infusion of IU/kg between two groups of patients, showing a higher IU infusion in the ICU group

P355 Two types, one protocol: diabetic ketoacidosis management outcomes compared

I Orleane 1 , L Tutane 2 , I Konrade 1

1 Riga East University Hospital, Riga, Latvia, 2 Riga Stradins University, Riga, Latvia

Critical Care 2026, 30 (Suppl 1): P355

Introduction: Standard diabetic ketoacidosis (DKA) protocols were developed mainly for type 1 diabetes mellitus (T1DM), with no separate treatment strategies for T1DM vs type 2 diabetes mellitus (T2DM) and no individualized insulin or potassium adjustment despite potassium’s link to glycaemic changes.With rising DKA cases in T2DM [1], it is unclear whether the same approach is equally effective for both. We aimed to compare DKA treatment response between T1DM and T2DM regarding insulin needs, metabolic correction, and treatment-related complications.

Methods: A retrospective analysis included 142 DKA patients treated in the Intensive Care Unit at Riga East University hospital. Serum pH, potassium and glucose levels were recorded over 24h period as well as given insulin infusion rate. Linear mixed models were used to analyse repeated measures.

Results: Of 142 patients, 53.5% had T1DM and 46.5% T2DM. Insulin infusion rates in the first 24 h were similar (2.1 vs 2.3 U/h), declined over time ( p < 0.001), and did not differ by type ( p = 0.62). Total insulin requirement was slightly higher in T2DM (55.7 vs 50.3 U, p = 0.12). Glucose decreased significantly ( p < 0.001) with consistently higher levels in T2DM ( p = 0.003) (Figure). Time to glucose normalisation was longer in T2DM (10.1 vs 8.6 h, p = 0.002) and varied by DKA cause ( p < 0.001), being longest in poor adherence and new-onset diabetes. Hypoglycaemia occurred in 9.2% and hypokalaemia in 33.1% without type differences. T1DM patients had lower baseline pH (7.02 vs 7.07, p = 0.046), but pH recovery was similar ( p = 0.11).

Conclusions: Both diabetes types responded similarly to standard DKA treatment, with comparable insulin needs and metabolic recovery. Glucose normalized more slowly in T2DM, especially in cases linked to poor adherence or new-onset diabetes. Overall, the protocol is effective for both types, though some patients may benefit from more individualized adjustment.

Reference

Ata F et al. BMC Endocr Disord 2023;3:193

Figure (abstract P355) Mean glucose decline during the first 24 h of DKA treatment in Type 1 and Type 2 diabetes

P356 Metformin as a protective factor of mortality in type 2 diabetic patients admitted to the ICU for septic shock: a multicentre retrospective cohort study. The SEPSMET study

V Glinez 1 , P Martel 2 , A Harrois 1 , J Duranteau 1 , A Rouquette 3 , M Werner 1

1 Hôpital Bicêtre, Anesthésie Réanimation Chirurgicale, Le Kremlin-Bicêtre, France, 2 Hôpital Bicêtre, Unité de Recherche Clinique, Le Kremlin-Bicêtre, France, 3 Hôpital Bicêtre, Service de Santé Publique et Epidémiologie, Le Kremlin-Bicêtre, France

Critical Care 2026, 30 (Suppl 1): P356

Introduction: Septic shock is a leading cause of death worldwide and a major concern in type 2 diabetic patients, who are particularly prone to infections. Metformin, the first-line treatment for type 2 diabetes, has pleiotropic effects that may benefit these patients in the context of septic shock. The primary objective was to assess the effect of metformin exposure on 30-day mortality in type 2 diabetic patients admitted to the intensive care unit (ICU) for septic shock.

Methods: This multicentric retrospective cohort study used data from the Clinical Data Warehouse of Greater Paris University Hospitals. Type 2 diabetic patients admitted to the ICU for septic shock between 2017 and 2022 were included and classified according to prior metformin exposure. A propensity score was generated from variables associated with both metformin exposure and 30-day mortality. A doubly robust approach, combining regression adjustment and inverse probability of treatment weighting, was used to estimate the effect of metformin on 30-day mortality.

Results: Among the 2740 included patients, 55% had prior metformin exposure (M +) and 45% received another antidiabetic treatment (M-). The cohort was predominantly male (69.5%), with a mean age of 68 ± 11 years; 72.9% had chronic hypertension, and 31.0% had chronic renal failure. Pulmonary infections were the most frequent source (47.3%). Baseline arterial lactate averaged 4.8 ± 4.7 mmol/L in the M + group vs. 4.4 ± 4.3 mmol/L in the M- group. Overall, 76.0% required mechanical ventilation and all patients received catecholamine vasopressors. Thirty-day mortality was 38.7% overall: 35.9% in the M + group and 42.1% in the M- group. After adjustment, metformin exposure was significantly associated with lower mortality (OR 0.75; 95% CI 0.65–0.89) (Figure). Length of stay, mechanical ventilation rates, and acute kidney injury incidence were comparable between groups.

Conclusions: Prior metformin exposure in type 2 diabetic patients with septic shock was associated with reduced 30-day mortality.

Figure (abstract P356) Forest plot of adjusted 30-day mortality following septic shock regarding metformin exposure

P357 Prognostic impact of serum vitamin E levels on functional outcomes in traumatic brain injury with intracranial lesions

SH Lee, YJ Seong, EJ Jung, SJ Ryu, YS Cho

Chonnam National University Hospital, Emergency Medicine, Gwangju, South Korea

Critical Care 2026, 30 (Suppl 1): P357

Introduction: Traumatic brain injury (TBI) remains a significant global health concern and is frequently accompanied by long-term neurological impairment. Although vitamin E is known for its antioxidative properties and potential neuroprotective effects, its role in predicting functional outcomes after TBI has not been well established. This study investigated whether serum vitamin E levels are associated with disability outcomes in patients with intracranial injuries.

Methods: A multicentre, prospective cohort study was conducted at five university hospitals from 2018 to 2020. Adult patients presenting to the emergency department with traumatic intracranial hemorrhage or diffuse axonal injury confirmed on radiological imaging were enrolled. Serum vitamin E concentrations (mg/dL) were grouped into four categories: low (0.0–5.4), low-normal (5.5–10.9), high-normal (11.0–16.9), and high (≥ 17.0). Multilevel logistic regression models were used to estimate adjusted odds ratios (AORs) for poor functional outcomes—defined as Glasgow Outcome Scale (GOS) scores 1–4—at 1 and 6 months.

Results: A total of 550 eligible patients were included. The median serum vitamin E level was 10.0 mg/dL (IQR 8.0–12.3). Disability was observed in 37.1% of patients at 1 month and 36.1% at 6 months. Compared with the high-normal group, the low vitamin E group had significantly higher risks of disability at both 1 month (AOR 3.66; 95% CI 1.62–8.27) and 6 months (AOR 2.60; 95% CI 1.15–5.85). The low-normal group also showed a modest but significant increase in disability risk at 1 month (AOR 1.63; 95% CI 1.08–2.48) and 6 months (AOR 1.60; 95% CI 1.04–2.43).

Conclusions: Lower serum vitamin E levels at presentation were associated with worse functional outcomes at 1 and 6 months in adults with intracranial traumatic brain injury. These findings suggest that vitamin E status may serve as an accessible prognostic biomarker for neurological recovery following TBI.

P358 Mechanisms of road traffic injury among severely injured patients in France, 2010–2024: a nationwide cohort study from the Traumabase registry

M Plaud 1 , S Archer 2 , A Harrois 1 , S Novelli 2 , M Werner 1

1 Hôpital Bicêtre, AnesthésieRéanimation Chirurgicale, Le Kremlin-Bicêtre, France, 2 Hôpital Bicêtre, Santé Publique et Epidémiologie, Le Kremlin-Bicêtre, France

Critical Care 2026, 30 (Suppl 1): P358

Introduction: Road traffic accidents (RTAs) remain a major cause of severe injury and death, with emerging mobility modes such as e-scooters and bicycles reshaping trauma epidemiology. We aimed to characterize injury patterns, care pathways, and outcomes across mechanisms of injury in France.

Methods: We analyzed data from the French Traumabase® registry including patients involved in RTAs from 2010 to 2024. Patients were categorized by mechanism of injury: motor vehicle, motorized two-wheel, bicycle, e-scooter, and pedestrian. Injury severity, management, and outcomes were compared across groups using multivariate Cox regression for 30-day intensive care unit (ICU) mortality.

Results: A total of 27,280 patients were analyzed, with a median age of 34 years (IQR 24–51) and 77% (21,046) being male. Traumatic brain injury (TBI) occurred in 45% (12,040) of patients, including severe TBI in 32% (3,838). Cyclists, e-scooter users, and pedestrians showed the highest TBI rates. Severe bleeding occurred in 6.9% (1,793), and 67% (18,005) sustained severe trauma. Surgery was performed in 52% of patients (13,116) within 30 days, predominantly orthopedic procedures (72%). 30-day ICU mortality was 7.8% (2,069), highest among pedestrians (15.7%) and lowest among motorized two-wheel vehicles users (5%) (Figure). In multivariate analysis, pedestrian mechanism, age ≥ 45, severe TBI, severe bleeding, and ISS > 16 independently predicted 30-day mortality.

Conclusions: Following RTA, injury patterns and outcomes differed markedly by mechanism. Pedestrians faced the highest mortality, while emerging micromobility users showed increasing neurotrauma burden. These findings call for mechanism-specific prevention strategies and continued adaptation of trauma systems to evolving mobility behaviours.

Figure (abstract P358) Cumulative incidence of 30-day ICU mortality and ICU discharge by injury mechanism

P360 Bacterial contamination and reprocessing efficacy of ultrasound probes in the emergency department: a prospective observational and randomized controlled study

J Sasaki 1 , M Kodama 2 , T Yamanaka 2 , R Yamamoto 2

1 Keio University School of Medicine, Emergency and Critical Care Medicine, Tokyo, Japan, 2 Keio University School of Medicine, Tokyo, Japan

Critical Care 2026, 30 (Suppl 1): P360

Introduction: Ultrasound imaging is indispensable in emergency departments (ED) owing to its rapidity, non-invasiveness, and cost-effectiveness; nevertheless, bacterial contamination of ultrasound probes, including multidrug-resistant organisms, poses a substantial risk of cross-infection. This study sought to elucidate the prevalence of bacterial contamination on ultrasound probes within the ED and to evaluate the effectiveness of a novel reprocessing device in mitigating this contamination.

Methods: A two-phase investigation was conducted in the ED. The first phase entailed a prospective observational study (April—July 2023) assessing bacterial contamination on patient-used probes via quantitative and qualitative swab cultures. Variables recorded included probe type, reprocessing method, use of probe covers, and presence of blood contamination. The second phase comprised a randomized controlled trial (August—December 2024) comparing standard reprocessing (ethanol wipes) with high-level disinfection (HLD) via an automated device (trophon®2) in alternate two-week intervals. The primary endpoint was the rate of probe contamination.

Results: During the observational phase, 75 of 101 probes (75%) exhibited bacterial contamination (median 10 CFU/swab). Predominant organisms included methicillin-resistant Staphylococcus epidermidis (MRSE, 18%), Staphylococcus aureus (SA, 18%), and coagulase-negative Staphylococci (CNS, 16%). Reprocessing method was the sole significant factor influencing colony counts; ethanol wipes were associated with reduced contamination ( p = 0.04). The RCT phase demonstrated a zero-contamination rate in the trophon®2 group (n = 109) compared to 37.3% (47/126) in controls ( p < 0.001) (Table).

Conclusions: Ultrasound probes in the ED are frequently subject to considerable bacterial contamination, including resistant strains; however, rigorous reprocessing using the trophon®2 device effectively eradicates contamination and may significantly attenuate cross-infection risk.

Table (abstract P360) Probe contamination rates, median colony counts, and main contaminants across the observational study and the RCT phases

P361 Macro-microcirculatory decoupling in septic shock patients admitted to the emergency department

L Trovato 1 , M Bellan 1 , X Monnet 2 , A Friuli 1 , C Rosset 1 , M Beltrame 1 , F Gavelli 3

1 Università degli Studi del Piemonte Orientale, Emergency Department, Novara, Italy, 2 Université Paris-Saclay, Service de Médecine Intensive-Réanimation, Le Kremlin-Bicetre, France, 3 Università degli Studi del Piemonte Orientale, Department of Translational Medicine, Novara, Italy

Critical Care 2026, 30 (Suppl 1): P361

Introduction: In septic shock patients the effects of fluid resuscitation are typically measured through macrocirculatory parameters, such as cardiac output. However, whether this adequately reflects tissue perfusion is still debated. Hence, we aimed to assess the concordance between aortic velocity–time integral (VTI) and capillary refill time (CRT) after fluid resuscitation in early septic shock, to identify potential macro-microcirculatory decoupling.

Methods: In septic shock patients admitted to the emergency department VTI and CRT were measured before and after each 500-mL fluid bolus administered by the treating physician. A VTI increase ≥ 15% defined macrocirculatory responders (RMACRO) whereas a CRT decrease ≥ 1 s defined microcirculatory responders (Rmicro). Concordance between continuous changes was assessed through the concordance correlation coefficient (CCC) and agreement between responder classifications was evaluated using Cohen’s kappa.

Results: Sixty-seven fluid boluses were administered to 44 patients (39% male). Median age was 77 [69–85] years, baseline lactate 3 [2–4] mmol/L and baseline CRT was 4 [3–5] seconds; 28-day mortality was 18%. Twenty-six boluses resulted in RMACRO with a VTI change of 24 [18–27] %, and 27 in Rmicro with a CRT change of -1 [-2 to -1] seconds. Overall, VTI changes did not correlate with CRT changes, with a CCC of -0.180 (95% IC -0.329 to -0.023) (Figure). When the agreement between RMACRO and Rmicro was evaluated, Cohen’s kappa was 0.32 (95% IC 0.09–0.56).

Conclusions: In septic shock patients at emergency department admission, fluid resuscitation demonstrated a decoupling between macro- and microcirculatory responses. These findings support a dual assessment of macrocirculation and microcirculation when evaluating the effects of fluid therapy.

Figure (abstract P361) Correlation between velocity–time integral changes and capillary refill time changes after a 500-mL fluid bolus

P362 Inferior vena cava collapsibility does not identify hydrostatic pulmonary oedema in dyspneic patients at emergency department presentation

E Fabbro 1 , M Bellan 1 , X Monnet 2 , M Crevola 1 , F Chiarini 1 , F Rastello 1 , F Gavelli 3

1 Università degli Studi del Piemonte Orientale, Emergency Department, Novara, Italy, 2 Università degli Studi del Piemonte Orientale, Service de Médecine Intensive-Réanimation, Novara, Italy, 3 Università degli Studi del Piemonte Orientale, Department of Translational Medicine, Novara, Italy

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Introduction: Inferior vena cava (IVC) respiratory variation is often used as an indicator of volume overload, to detect venous congestion in patients with acute dyspnea presenting to the Emergency Department (ED). However, whether IVC collapsibility is reliable in detecting hydrostatic pulmonary oedema (HPO) is still debated.

Methods: In this prospective observational study, we enrolled patients presenting to the ED for dyspnea and acute respiratory failure. The IVC diameter was measured both at end-inspiration (IVCINSP) and expiration (IVCEXP) to calculate the IVC collapsibility index (ΔIVC) ((IVCEXP − IVCINSP)/IVCEXP × 100). Measurements were obtained at presentation (T0) and after 1 h (T1). The area under the receiver operating characteristic (AUROC) analysis was used to evaluate the ability of ΔIVC to detect HPO.

Results: We enrolled 51 patients with acute respiratory failure (26 HPO, 25 non-HPO). Thirty-four were female and the median age was 81 [74–89] years. Pro-BNP was 9556 [2315–19804] ng/L in HPO patients and 516 [270–1555] ng/L in non-HPO. IVCEXP was significantly higher in HPO than non-HPO (21.0[18.0–23.0] mm vs. 15 [13.6–19.0] mm, respectively; p = 0.001), as well as IVCINSP (18.0 [11.3–20.7]mm vs.9.1[7.1–13.8] mm, respectively; p = 0.002). ΔIVC at T0 was not different between HPO and non-HPO patients (16.7 [4.8–38.9]% vs.40 [17.8–52.8]%, respectively; p = 0.052). Conversely, ΔIVC at T1 was significantly different between the two groups (17.4 [8.3–27.5]% for HPO vs. 49.2 [19.1–56.7]% for non-HPO; p = 0.002). ΔIVC performed poorly in detecting HPO at T0 with an AUROC of 0.657 [95% IC 0.512–0.783] and a cut-off of 38.9% (Figure). ΔIVC at T1 showed an AUROC of 0.748 (0.607–0.859) and a cut-off of 32.2% which was not significantly different from the one of T0 ( p = 0.389 for AUROC comparison).

Conclusions: In patients presenting to the ED for acute respiratory failure ΔIVC demonstrates poor accuracy for identifying HPO. Therefore, its use for this purpose in this setting is not recommended.

Figure (abstract P362) Area under the receiver operating curve for the inferior vena cava collapsibility index to detect hydrostatic pulmonary oedema at ED presentation

P363 Haemoglobin and protein changes detect hydrostatic pulmonary oedema in dyspneic patients at the emergency department

M Crevola 1 , M Bellan 1 , X Monnet 2 , E Fabbro 1 , E Viganò 1 , F Rastello 1 , M Pirisi 3 , JL Teboul 2 , F Gavelli 4

1 Università degli Studi del Piemonte Orientale, Emergency Department, Novara, Italy, 2 Université Paris-Saclay, Service de Médecine Intensive-Réanimation, Le Kremlin-Bicetre, France, 3 Università degli Studi del Piemonte Orientale, Internal Medicine, Novara, Italy, 4 Università degli Studi del Piemonte Orientale, Department of Translational Medicine, Novara, Italy

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Introduction: In hydrostatic pulmonary oedema (HPO) the transudation of protein-free fluid from blood vessels to the pulmonary interstitium has been shown to determine a variation in haemoglobin (ΔHb) and plasma protein concentration (ΔProt). In this study we aim at investigating whether such changes can be used to detect HPO in dyspnoeic patients presenting to the emergency department (ED).

Methods: In this prospective observational study, we enrolled patients admitted to the ED for dyspnoea and acute respiratory failure. Vital signs and blood samples were collected at baseline (T0) and after one hour (T1), along with clinical, radiological and demographic data. Patients were divided into HPO and non-HPO according to clinical, radiological and pro-BNP results, and the ability of ΔHb and ΔProt between T1 and T0 to detect HPO was evaluated.

Results: Fifty-four dyspnoeic patients (19 males; age 83[73–89] years) were enrolled, of whom 27 had HPO. Pro-BNP was 9556[2315–19804]ng/L in HPO and 546[239–1220]ng/L in non-HPO. Baseline Hb did not differ between HPO and non-HPO patients (11.6[10.1–13.2]g/dL vs. 12.5[10.3–13.8]g/dL; p = 0.368), whereas at T1 it was lower in the HPO group (11.2[9.7–12.7]g/dL vs. 12.8[10.9.14.0]g/dL; p = 0.044). ΔHb was significantly higher in HPO patients (-5.3[-6.2 to -3.6]% vs. 1.4[-2.8 to 3.4]%, respectively; p < 0.001) (Figure). ΔHb detected HPO with an area under the receiver operating characteristics (AUROC) of 0.847[0.723–0.930] and a cut-off of -3.8%. Baseline plasma protein levels were similar between HPO and non-HPO (69.2[66.8–73.0]g/L vs. 69.2[63.0–72.2]g/dL; p = 0.337). At T1 protein levels remained comparable (66.8 [63.7–70.9]g/L vs. 68.6 [63.1–72.8]g/dL, respectively; p = 0.429). However, ΔProt was significantly higher in HPO patients (-5.3[-6.2 to -3.6]% vs. 1.4[-2.8 to 3.4]%, respectively; p < 0.001), detecting HPO with an AUROC of 0.843[0.713–0.931] and a cut-off of -4.1%.

Conclusions: Both ΔHb and ΔProt detect HPO in patients admitted to the ED for dyspnoea and acute respiratory failure.

Figure (abstract P363) Percentage haemoglobin changes in HPO and non-HPO patients

P364 Prognosis of cardiogenic acute pulmonary edema in the emergency department: value of the emergency heart failure mortality risk grade score

Z Youssef, W Demni, Y Walha, D Hamdi, I Aloui, W Bahria, N Nouira

Monji Slim Hospital, Emergency Department, Tunis, Tunisia

Critical Care 2026, 30 (Suppl 1): P364

Introduction: The Emergency Heart Failure Mortality Risk Grade (EHMRG) was proposed to predict mortality in patients with acute heart failure. Our Study aimed to evaluate the prognostic value of the EHMRG score in terms of seven days, one month, and six months mortality in patients presenting with cardiogenic acute pulmonary edema(APE) and to identify predictive factors of 7-day mortality in these patients.

Methods: We conducted a prospective, analytical study in the emergency department of Mongi Slim Hospital in Tunisia, over an 18-month period. Patients admitted for APE were included. The EHMRG score was calculated at admission. The primary endpoint was 7-day mortality. We assessed predictors of 7-day mortality and evaluated the prognostic value of the EHMRG score for 7-day, 1-month, and 6-month mortality.

Results: A total of 224 patients were included. The mean age was 71 ± 11 years. The gender ratio was 1.07. The main comorbidities were hypertension (73.3%), diabetes (48.7%) and coronary artery disease (34.8%). The median EHMRG score was 44[-125–351]. According to the EHMRG score, patients were classified as "very high risk" and "high risk" in 44.1% and 22.8% of cases, respectively. Cumulative mortality at day seven, one month, and six months was 17%, 22% and 28%, respectively. The areas under the ROC curves for EHMRG score regarding mortality at day 7 were respectively 0.84 ( p < 10 –3 ), 0.87 ( p < 10 –3 ) and 0.85 ( p < 10 –3 ). A cut-off value of 50.2 was identified for 7-day mortality (Se = 87%, Sp = 71%, PPV = 38%, NPV = 96%). In multivariate analysis, independent predictors of 7-day mortality were: history of chronic kidney disease (p = 0.02), prior hospitalization for APE ( p = 0.02), signs of respiratory distress ( p < 10 –3 ), and EHMRG score ≥ 50.2 ( p = 0.001).

Conclusions: The EHMRG score, easy to calculate in the emergency setting, helps to predict short and medium-term mortality in patients with cardiogenic APE, thereby encouraging clinicians to optimize management to improve patient outcomes.

P365 FEDU – REMAP: frequent emergency department users – re-entry and mortality predictors

A Rubinetti 1 , F Gavelli 2 , M Ratti 3 , F Balzano 1 , M Bellan 1

1 Università degli Studi del Piemonte Orientale, Emergency Department, Novara, Italy, 2 Università degli Studi del Piemonte Orientale, Department of Translational Medicine, Novara, Italy, 3 Università degli Studi del Piemonte Orientale, Medical Executive Office, “Maggiore della carità” Teaching Hospital, Novara, Italy

Critical Care 2026, 30 (Suppl 1): P365

Introduction: Frequent emergency department users (FEDU) pose a challenge for the Emergency Physician as repeated visits may mask evolving or missed life-threatening conditions. This study aimed to identify predictors of re-entry and 90-day mortality in patients with at least 3 ED visits for the same complaint within one year.

Methods: In this retrospective single-centre study we collected demographic, past medical, laboratory and radiological data of patients with ≥ 3 ED visits for the same reason over one year. Patients were grouped by presenting complaint, and for each category we assessed predictors of re-entry or mortality within 90 days.

Results: Out of 87,087 ED admissions of two years (2023–2024) in a tertiary teaching hospital, 1891 FEDU patients were identified (44.6% women, mean age 60 ± 23 years). Main complaints were mostly abdominal (20.3%), neurological (14.7%) and cardiovascular (8.9%) symptoms. Most of them were discharged at home (60.5%), 26% were admitted to an hospital ward and 9.1% left before a full medical evaluation. Overall, 864 patients had a 90-day event: 101 (11.7%) deaths and 763 (88.3%) readmissions. In abdominal FEDU, performing liver function blood tests during previous ED visits or routine blood tests during the 3rd visit were protective for 90-day events (HR 0.51[0.35–0.73] and HR 0.60[0.45–0.81] respectively; p < 0.001). In neurological FEDU, performing blood tests, brain CT scan or neurological consult before the 3rd access reduced the risks of events (HR 0.39 [0.23–0.66], HR 0.59 [0.42–0.83] and HR 0.52 [0.35–0.77], respectively; p < 0.001), but a neurological consult during the 3rd visit, did not (HR 0.68 [0.46–1.01]; p = 0.067). Notably, in cardiovascular FEDU troponin testing or cardiological consults both before and during the 3rd ED visit did not reduce events ( p > 0.05) (Figure).

Conclusions: These preliminary data identify potential predictors of adverse outcomes among FEDU. Integrating them into clinical practice may support earlier recognition and management of high-risk patients.

Figure (abstract P365) Survival analysis for patients with cardiovascular complaints based on whether they underwent a troponin test during the previous emergency admissions

P366 Intensive care admissions for deliberate self-poisoning a retrospective cohort review

J Thomson 1 , E Smith 1 , CA McKenzie 2

1 University Hospital Southampton, Pharmacy, Southampton, UK, 2 NIHR BRC Southampton, Perioperative and Critical Care, NIHR BRC Southampton, Perioperative and Critical Care, Southampton, UK

Critical Care 2026, 30 (Suppl 1): P366

Introduction: Deliberate self-poisoning (DSP) leads to 160,000 hospital admissions annually in the UK. A proportion require admission to the intensive care unit (ICU), for all poisonings between 3–10% [1]. The INTOXICATE study collected international data on poisoned patients, although lacked specific data on DSP [2]. This aim of our evaluation was to describe demographics and outcomes for ICU admissions in Southampton due to DSP.

Methods: This retrospective cohort review was registered as a service evaluation; ethics approval was waived. ICU adult admissions over 5 years coded as to “intentional self-poisoning” were identified via multiprofessional notes, categorised and reported in MS Excel, focus on demographics, need for ventilation, ICU mortality and causative agent.

Results: 94 patients (52% female) were “intentional self-poisoning” ICU admissions. Median age was 44 (17–87). 5 of 94 died, 9 were discharged home and 80 transferred to general wards. 69% were intubated on ICU admission, with 4% intubated after ICU admission. 37% required vasopressor support and 5% renal replacement therapy (RRT). Most DSP were mixed, 64 (67%) were mixed ingestions followed by amitriptyline. Most admissions, (73%) were less than 3 days duration. Previous mental health, neurodiversity and psychiatric follow up were poorly documented.

Conclusions: In our cohort age and gender were similar to INTOXICATE (52% vs 53%, 44 vs 41 respectively). Our largest group were mixed ingestions (67% vs 50%), followed by amitriptyline. More patients in our cohort were intubated, received vasoactive agents but fewer required RRT. Limitations of our review include missed patients due to coding, limited analysis and follow up. Our initial capture accounted for < 1% of total ICU admissions. Future work will focus, wider data capture, on previous mental health conditions, neurodiversity, psychiatric history and ICU medication reconciliation for this vulnerable group.

References Huser et al. Intensive Care Med 2025;51:2378–2391 Zwaag et al. Crit Care 2024;28:316

P367 Significance of substance use disorder (SUD) in ICU

MJ Jacka 1 , P Thompson 2 , T Hewer 3 , V Lau 2 , O Rewa 2 , P Brindley 2 , K Macala 2 , D Kutsogiannis 2

1 University of Alberta, Anesthesiology and Critical Care, Edmonton, Canada, 2 University of Alberta, Critical Care, Edmonton, Canada, 3 University of Alberta, Critical Care Research, Edmonton, Canada

Critical Care 2026, 30 (Suppl 1): P367

Introduction: SUD-related ICU admissions increased from ~ 10% in the 1990’s to ~ 30% in 2025 [1]. The characteristics of patients with SUD as an admission or contributory diagnosis remain unclear. We studied factors and outcomes associated with survival at a major Canadian urban hospital (Table).

Methods: The Royal Alexandra Hospital is an 869-bed urban hospital with 29 med-surg-trauma ICU beds in Edmonton AB Canada. We conducted a cohort study of all SUD-related admissions to ICU (DSM5 criteria) from June 1 2024 to May 31 2025. We reported data as absolute numbers and compared these using student's t-test or Chi-squared testing as appropriate.

Results: Of 1385 patients, 426 (31%) had SUD as a 1 o or 2 o diagnosis. Survivors and non-survivors were not differentiated on the basis of age (44.7 vs 43.9) nor gender (male/female 73.1/26.6 vs 72.7/28). APACHE was higher among non-survivors (26.9/17.7, p < 0.001) but LOS was briefer (6.9 vs 4.8 days, p = 0.002). Fewer survivors were homeless (44% vs 57.8%, p = 0.01). More survivors had chronic pain (13.6 vs 4.7%, p = 0.006). Fewer survivors had previous overdose (22.1 vs 37.5%, p = 0.002) or substance-induced psychosis (6.1 vs 11.7%, p = 0.07). Of 128 non-survivors, 84 (66%) died from hypoxic-ischemic encephalopathy, virtually all having presented after cardiac arrest. Of these, 29 (35%) met clinical criteria for neurologic determination of death and 24 (29%) went to organ donation.

Conclusions: SUD accounted for or contributed to 31% of ICU admissions, representing a major increase over time. Non-survival was associated with homelessness, previous overdose, substance-induced psychosis, and opioid use. No association was seen with stimulant or alcohol use. We found no association with gender, race, or age. Two-thirds of SUD-related deaths were due to hypoxic-ischemic encephalopathy, most occurring after cardiac arrest associated with overdose, and many of these going to eventual organ donation. Further study of factors and outcomes is warranted.

Reference Baldwin WA et al. Chest 1993;103:21–25

Table (abstract P367) Survivors vs non-survivors

P368 Variability, influencing factors, and clinician stress in ICU admission decision-making: the ICUPASS study

M De Silva Morgan, A Binuraj, O Reeve Chen, C Chacko, T Veenith

Royal Wolverhampton Trust, Intensive Care, Wolverhampton, UK

Critical Care 2026, 30 (Suppl 1): P368

Introduction: ICU admission decisions are complex and vary widely between clinicians [1]. This study quantified variability in admission decisions, identified influencing factors, and measured associated stress using standardised clinical vignettes.

Methods: A cross-sectional survey of ICU clinicians across the West Midlands, UK captured ratings of ten vignettes on likelihood of admission, decision-making stress, and admission likelihood with unlimited resources (10-point Likert scales) (Figure). Reasons for non-admission were recorded. Clinicians were grouped as decision-makers (DMs: consultants/senior registrars) or non-decision-makers (NDMs: nurses, junior doctors, ACCPs). Data were summarised using median (IQR) and compared with Mann–Whitney U, Friedman, and chi-square tests.

Results: Eighty-four clinicians (47 DMs; 37 NDMs) completed all vignette ratings. Admission likelihood showed marked heterogeneity (median 5, IQR 6). Overall likelihood did not differ between groups, though DMs identified more “clear reject” cases. NDMs reported higher stress than DMs (median 5 vs 4, p < 0.001). Ambiguous cases generated the most variability and stress. Admission likelihood decreased when resources were unlimited (median 3 vs 5, p < 0.001). “Futility” was the most common reason for non-admission (32.3%).

Conclusions: ICU admission decisions show substantial inter-clinician variability and significant stress, especially among NDMs and in ambiguous cases. Structured decision-support tools may help improve consistency and reduce psychological burden on ICU staff.

Reference Escher M et al. Health Serv Res 2019;54:474–483

Figure (abstract P368) Overview of ICUPASS study

P369 Association between ICU admission time and 24-h mortality: a single-center retrospective observational study

K Shirakawa 1 , Y Katsura 2 , H Watanabe 1 , R Seo 1

1 Kobe City Medical Center General Hospital, Department of Emergency Medicine, Kobe, Hyogo, Japan, 2 Kobe City Medical Center General Hospital, Department of Anesthesiology, Kobe, Hyogo, Japan

Critical Care 2026, 30 (Suppl 1): P369

Introduction: ICUs admit patients 24/7. Nighttime admissions have been linked to higher mortality [1], but not in intensivist-staffed settings [2]. Physician handovers may worsen outcomes [3]. Examining admission time–outcome associations is important for resource allocation, yet evidence remains limited. We investigated whether ICU admission time is associated with 24-h mortality in a 24/7 intensivist-staffed ICU, hypothesizing higher risk at night and around handovers.

Methods: This single-center retrospective observational study used data from the Emergency-ICU of Kobe City Medical Center General Hospital registered in Japanese Intensive care PAtient Database (JIPAD). All patients admitted Apr 2017–Jul 2025 were included. Admission hour was modeled as a continuous predictor in logistic regression with restricted cubic splines (ref 14:00). Covariates: age, sex, APACHE II, mechanical ventilation, comorbidities (respiratory failure, metastatic cancer, heart failure, liver failure, cirrhosis, dialysis, immunosuppression, lymphoma, acute myeloid leukemia, multiple myeloma), and admission diagnosis category. 95% CIs were obtained by parametric bootstrap. Sensitivity analyses used hour categories. Admission-time distribution was shown with a violin plot.

Results: Among 5,765 patients, 204 (3.5%) died within 24 h. Admissions clustered at 15:00–20:00. Adjusted risk increased around handovers: at approximately 07:00, OR 1.92 (95% CI 1.23–2.89); at approximately 16:00, OR 1.16 (0.91–1.45). Nighttime (00:00–07:00) showed no significant association, OR 1.25 (0.79–1.94) (Figure). Sensitivity analyses were consistent.

Conclusions: ICU admission time was associated with 24-h mortality. While nighttime admission itself was not linked to a significant increase in risk, admissions during and around handover periods were associated with higher mortality.

References Zajic P et al. Sci Rep 2019;9:12,533 Brunot V et al. PLoS One 2016;11:e0168548 Farid M et al. JAMA Netw Open 2021;4:e213040

Figure (abstract P369) Adjusted and unadjusted odds ratios (ORs) for 24-h mortality according to ICU admission time, modeled with restricted cubic splines. Shaded areas represent 95% confidence intervals. Vertical bars indicate physician and nurse handover periods. The lower panel shows the distribution of admission times (violin plot)

P370 Delayed admissions to critical care in a tertiary centre and its complex web of causes

A Naito, A Jervis, S Kent, J Fideles, E Madine, V Metaxa

King´s College Hospital NHS Foundation Trust, Critical Care Department, London, UK

Critical Care 2026, 30 (Suppl 1): P370

Introduction: Delayed ICU admissions are associated with increased risk of mortality, higher cost [1], and is a quality indicator. They are defined as > 4 h from decision-to-admit (DTA) time [2]. The Intensive Care National Audit and Research Centre (ICNARC) reports show a significantly higher proportion of delayed admissions at our hospital compared to similar units. Our aim was to ascertain incidence and causes of delayed ICU admissions.

Methods: Single UK tertiary centre retrospective and prospective observational study. Data were collected from a) electronic records and ICNARC reports of adults admitted to ICU 01/10/2024–31/03/2025; b) contemporaneous electronic forms completed by members of the critical care outreach team (CCOT) and ICU bed managers at the time of admission. Planned admissions and patients with no DTA times were excluded.

Results: We identified 597 patients. Median age was 60 years; 36% were female. 19% were delayed admissions with a median 5.2 h. Non-delayed admissions had a median 1.7 h ( p < 0.001). There were no significant differences in demographics, ICU length of stay and mortality between the two groups. 17% of delayed admissions had > 1 cause of delay. Capacity, requiring a procedure/imaging, and cleaning/porter delays were the commonest cited reasons. ICU factors affected 13% of delayed admissions (Figure).

Conclusions: Our ICU admissions are delayed mainly due to pre-ICU and hospital factors. Contrary to previous literature, delayed admissions were not associated with increased ICU length of stay or mortality, which could be in part due to our robust CCOT and ability to provide critical care treatment outside ICU. 42% of patients did not have a reason documented for their delayed admission. Next steps are to improve DTA documentation and focus on a detailed qualitative analysis of the reasons for delayed admissions.

References

Kiekkas P et al. Biomed Research Intl 2022;2022:4083494 Intensive Care Society (ICS) and Faculty of Intensive Care Medicine (FICM). GPICS v2.1, 2022

Figure (abstract P370) Causes of delayed ICU admissions (CVC = central venous catheter)

P371 Beyond NEWS: external validation of machine learning early warning scores for clinical deterioration

T Bakkes 1 , J Van Lieshout 2 , I Paulussen 3 , A De Bie Dekker 3 , S Turco 2 , M Mischi 2 , U Kaymak 2 , A Bouwman 3

1 Eindhoven University of Technology, Electrical Engineering, Eindhoven, Netherlands, 2 Eindhoven University of Technology, Eindhoven, Netherlands, 3 Catharina Hospital Eindhoven, Eindhoven, Netherlands

Critical Care 2026, 30 (Suppl 1): P371

Introduction: Early warning scores (EWS) help monitor hospitalized patients, but conventional systems like the National Early Warning Score (NEWS) focus on current status and are less suited for predicting future complications. Machine learning-based models such as the Advance Alert Monitor (AAM) and Deep Early Warning System (DEWS) aim to improve predictive accuracy [1, 2]. However, external validation and direct comparisons remain limited. We externally validated AAM and DEWS in a large independent cohort and compared their performance against NEWS and each other.

Methods: We conducted a retrospective study using electronic health record data from Catharina Hospital, Eindhoven, the Netherlands, collected between December 2018 and January 2023. The primary composite outcome was clinical deterioration, defined as in-hospital mortality, unplanned ICU admission, or acute surgery. The AAM and DEWS models were each optimized on a training-validation set and evaluated on an independent test set. Performance was compared to the National Early Warning Score (NEWS).

Results: Both data-driven models outperformed the conventional NEWS in predicting clinical deterioration. The AUROC was 81.7% for AAM, 80.0% for DEWS, and 72.8% for NEWS (Figure). In terms of precision-recall performance, DEWS achieved the highest AUPRC at 37.9%, followed by AAM at 35.6%, and NEWS at 26.4%, indicating superior early detection capability for machine learning-based scores.

Conclusions: Data-driven early warning scores demonstrated superior predictive performance compared to the conventional NEWS for identifying patients at risk of clinical deterioration. Both AAM and DEWS achieved higher discrimination and precision. These findings support the potential of machine learning-based models for improving early detection and guiding timely interventions in hospitalized patients.

References Escobar GJ et al. N Engl J Med 2020;382:1951–1960 Shamout FE et al. IEEE J Biomed Health Inform 2020;24:437–446

Figure (abstract P371) Performance curves comparison

P373 The Dutch ICUdata warehouse: standardised and scalable infrastructure for observational ICU data

OV Sigling, AR Jagesar, LA Biesheuvel, M Otten, M Hoogendoorn, PWG Elbers

Amsterdam UMC, Amsterdam, Netherlands

Critical Care 2026, 30 (Suppl 1): P373

Introduction: Single-hospital observational datasets generalise poorly due to patient and practice variations, and their size restricts prediction model complexity, but combining hospital datasets creates legal, technical and interoperability challenges. We present the Dutch ICUdata warehouse, a multi-centre, multi-EHR standardised data warehouse that addresses these challenges, allowing participating hospitals access to a large, diverse and scalable dataset for machine learning and AI research (Figure).

Methods: A data-use agreement developed with legal and privacy experts governs participation, supported by a participant council ensuring federated oversight. Hospitals deliver raw tabular data from all historical adult ICU admissions, extracted from Epic, HiX or Metavision. An automated, EHR-specific data pipeline transforms the data into the Observational Medical Outcomes Partnership Common Data Model (OMOP-CDM), a widely used healthcare database standard. Mapping of all source clinical concepts to OMOP Standard vocabularies is done by domain experts with assistance from a large language model, resulting in a high-quality, clinically comprehensive dataset suitable for a wide range of research questions. Data from the National Intensive Care Evaluation registry has been linked for validation and outcome enrichment.

Results: Currently, 12 hospitals have signed the data-use agreement of which 8 have delivered data, resulting in a database of 117,430 patients and 130,472 admissions, with up to 20 years of data per hospital. It contains data from both academic and general hospitals of different sizes from across the Netherlands. The automatic pipeline allows rapid scaling with the addition of new hospitals.

Conclusions: ICUdata provides a standardised, growing resource for Dutch ICU research that overcomes key barriers to multi-centre collaboration, demonstrating that national-scale ICU data standardisation is feasible. Future developments will focus on expanding hospital participation across the Netherlands.

Figure (abstract P373) Schematic overview of the ICUdata Warehouse data pipeline

P374 AmsterdamUMCdb Van Gogh OMOP: the largest openly accessible European ICU database

OV Sigling, LA Biesheuvel, PJ Thoral, M Otten, A Jagesar, MC Reuland, P Hilders, PWG Elbers

Amsterdam UMC, Amsterdam, Netherlands

Critical Care 2026, 30 (Suppl 1): P374

Introduction: AmsterdamUMCdb 1.0, released in 2020 as the first openly accessible European ICU database, consisted solely of data from one campus of the now merged Amsterdam University Medical Center [1]. The forthcoming AmsterdamUMCdb Van Gogh OMOP combines data from both campuses and incorporates the Epic EHR, substantially enlarging the cohort and broadening temporal coverage. The dataset has been transformed into the Observational Medical Outcomes Partnership Common Data Model (OMOP-CDM), making it fully FAIR (Findable, Accessible, Interoperable, Re-usable). Its public release is planned before ISICEM 2026.

Methods: An automatic data pipeline transforms all clinical, device and laboratory tables from both Metavision and Epic to the OMOP-CDM. Mapping of all source clinical concepts to OMOP Standard vocabularies was done by domain experts with assistance from a large language model, resulting in a high-quality, clinically comprehensive dataset. We applied the same risk-based de-identification framework validated for v1.0. Data from the National Intensive Care Evaluation registry has been linked for validation and enrichment of diagnoses and outcomes.

Results: AmsterdamUMCdb Van Gogh OMOP currently comprises 65,110 patients with 78,750 ICU admissions occurring between 2003 and 2024, representing a more than threefold increase in size. The dataset contains more than 2,000 clinical concepts, including high-frequency laboratory measurements, vital signs, and medication administrations.

Conclusions: AmsterdamUMCdb Van Gogh OMOP will become the largest openly accessible high-resolution ICU database to date. It integrates data from three different EHR systems into a single GDPR-compliant and OMOP-mapped dataset. By including both campuses of Amsterdam UMC, it significantly increases cohort size and heterogeneity. The resource will enable reproducible machine learning research, cross-centre benchmarking, and external validation of clinical AI tools.

Reference Thoral PJ et al. Crit Care Med 2021;49:p e563-e577

P376 External validation of preoperative risk models for adverse outcomes after major non-cardiac surgery in frail patients

EM Groenewegen

St Antonius Ziekenhuis, Anesthesiology, Nieuwegein, Netherlands

Critical Care 2026, 30 (Suppl 1): P376

Introduction: Effective risk stratification before major surgery can support clinical decision-making in frail patients. However, preoperative risk models have been derived nor validated in this population. This study aimed to externally validate the predictive performance of established preoperative risk models in frail patients.

Methods: A retrospective cohort study in frail patients who underwent elective major non-cardiac surgery between November 2015 and February 2025. All patients had a comprehensive frailty assessment and multidisciplinary team evaluation prior to surgery. Risk scores were calculated for five established models: SORT, POSPOM, SURPAS, RQI and ACS-NSQIP. Outcomes of interest were 120-day mortality, major complications and non-home discharge. Model performance was evaluated with discrimination and calibration. Models with acceptable performance were then evaluated to determine whether adding frailty characteristics enhanced risk prediction.

Results: Among 910 included patients, 66 died (7.3%), 189(20.8%) had a severe complication and 128(14.1%) were not discharged home. Predictive performance for mortality was not acceptable for SORT, POSPOM, SURPAS and RQI, indicating that these models are clinically unsuitable in frail patients. For ACS-NSQIP, discrimination was moderate for mortality (AUROC 0.64 (95%CI 57–0.70), 0.66 (0.61–0.79) for major complications and 0.63(0.58–0.67) for non-home discharge. Calibration demonstrated moderate agreement between predicted and observed outcomes. Adding frailty characteristics to ACS-NSQIP improved model fit, but did not enhance predictive performance.

Conclusions: Most commonly used risk models cannot be used for preoperative risk stratification in frail patients. ACS-NSQIP showed moderate discrimination and calibration, indicating limited clinical potential.

P377 Variables used in the decision-making process for patient transitions within the postoperative setting: an interview study

E Lemmens, M Afonso, M Mischi, I Paulussen, RA Bouwman, S Turco, A Akkermans

Catharina Ziekenhuis, Anesthesiology, Eindhoven, Netherlands

Critical Care 2026, 30 (Suppl 1): P377

Introduction: The use of machine learning in the decision-making process for patient transitions offers great potential to relieve the workload within healthcare. To build a model that can advise in patient transitions, it is crucial to first identify which variables should be considered for incorporation. Therefore, this study aimed to identify variables used in the decision-making process during patient transitions postoperatively.

Methods: In this interview study, physicians and nurses on surgical wards of the Catharina Hospital Eindhoven, the Netherlands were contacted between October and November 2025. In a concurrent nested mixed-method design a Likert scale questionnaire was used to verify 9 open-ended questions. Member checks were performed to verify correct interpretation of answers. Interviews were audio taped and transcribed afterwards. Descriptive and thematic analyses were performed. The need for informed consent was waived.

Results: 15 participants were interviewed (11 (8 SD) years of experience, including 4 specialists, 9 (specialized) nurses and 2 physician assistants). Activity of daily living (73%), intake (60%), mobilization (60%), pain (40%) and vital signs (40%) were valued most in the decision to discharge a patient. The variable vital signs (100%) was the most important when considering transfer to the ICU followed by occupation of available nurses (60%) (Figure).

Conclusions: Vital signs, activity of daily living, intake, mobilization and pain are the most important variables for healthcare professionals guiding patient transitions in a surgical ward. These variables should be considered for inclusion in future models aiming to predict within-hospital patient transitions.

Figure (abstract P377) Value of variables within the decision-making process for patient transitions

P378 Physiological and anatomical severity indices predict early adverse outcomes in critically ill polytrauma patients

B Queiroz, I Pinto, R Duarte, F Bessa, JM Ribeiro

Unidade Local de Saúde Santa Maria, Intensive Care Unit, Lisboa, Portugal

Critical Care 2026, 30 (Suppl 1): P378

Introduction: Multisystemic trauma remains a major cause of complications and mortality. Epidemiological data collecting seems essential to increase efficiency of care pathways. Timely identification of high-risk polytrauma patients is crucial to optimize early interventions and resource allocation, making reliable severity prediction scores determinant for rapid triage and clinical decision-making.

Methods: Retrospective data from 378 polytrauma admissions to a tertiary ICU were collected across a four-year period. Statistics analysis, including multivariable logistic regression, was used to assess predictors of mortality, ICU length of stay (LoS) and complications.

Results: Patients were predominantly male (81.7%), 56.5% were younger than 55 years. Mean Injury Severity Score (ISS) was 37, Revised Trauma Score (RTS) 6.5 and TRISS-predicted survival 61.6%. Pre-ICU surgery occurred in 60%, mainly damage-control procedures. Orthopaedic surgery was the most frequent (36.3%), followed by neurosurgery (18.4%). Major complications included rhabdomyolysis (44.9%), coagulopathy (37.4%) and haemorrhagic shock (24.8%). ISS correlated with ICU-LoS ( ρ = 0.31; p < 0.001) and with 24h mortality (r = 0.25; p < 0.001), while RTS and TRISS showed inverse correlations. TRISS was associated with worse early outcomes (r = -0.28, p < 0.001). SAPS II predicted 24h mortality (OR 1.06; p = 0.008). ISS independently predicted major complications (OR 1.02; p = 0.012) and transfusion use (OR 1.03; p < 0.001). Trauma type and surgical timing were not associated with mortality. SAPS II, SOFA and ISS showed good discrimination for hospital mortality (AUC 0.81, 0.78 and 0.74).

Conclusions: Physiological and anatomical severity scores (particularly SAPS II, ISS and RTS) are strong predictors of early mortality, complications and transfusion requirements in polytrauma patients. Their systematic application can improve early risk stratification and clinical prioritisation, supporting structured multidisciplinary management to reduce morbidity and shorten ICU stay.

P379 Predictive value of the reverse shock index multiplied by Glasgow Coma Scale score for mortality in ICU patients with heatstroke: a multicenter retrospective study

L Shi 1 , Z Zhang 1 , M He 1 , S Chen 1 , R Wang 2 , X Zhang 1

1 West China Hospital, Sichuan University, Department of Critical Care Medicine, Chengdu, China, 2 The First Medical Centre, Chinese PLA General Hospital, Department of Neurosurgery, Beijing, China

Critical Care 2026, 30 (Suppl 1): P379

Introduction: To evaluate and compare the predictive value of the reverse shock index multiplied by Glasgow Coma Scale score (rSIG) with the shock index (SI), Glasgow Coma Scale (GCS), and quick Sequential Organ Failure Assessment (qSOFA) score for short-term mortality in intensive care unit (ICU) patients with heatstroke.

Methods: This multicenter retrospective study enrolled 671 heatstroke patients admitted to ICUs across 83 hospitals in southwest China. The predictive performance was compared using receiver operating characteristic (ROC) curves. Independent risk factors were identified via univariate and multivariate logistic regression, and a nomogram prediction model incorporating rSIG and laboratory markers was developed and validated.

Results: Among the cohort, 120 patients (17.88%) died. ROC analysis demonstrated that rSIG had the highest predictive AUC of 0.739 (95% CI: 0.687–0.782), outperforming SI (0.688), GCS (0.703), and qSOFA (0.613) (Figure). Multivariate analysis identified prothrombin time (PT), creatinine (Cr), lactate (Lac), and rSIG as independent predictors. The nomogram integrating these four factors showed good discrimination, with an AUC of 0.80 (95% CI: 0.77–0.84). Subgroup analysis confirmed the consistent predictive value of rSIG.

Conclusions: The rSIG is a simple and effective early screening tool for rapid risk stratification in ICU patients with heatstroke. The predictive model combining rSIG with PT, Cr, and Lac further enhances prognostic accuracy, offering significant clinical utility.

Figure (abstract P379) The figure compares the predictive performance of four scoring systems for mortality: the reverse Shock Index multiplied by Glasgow Coma Scale score (rSIG), Shock Index (SI), Glasgow Coma Scale (GCS), and quick Sequential Organ Failure Assessment (qSOFA). Among these, rSIG demonstrated the highest discriminative ability, with an area under the receiver operating characteristic curve (AUC) of 0.739 (95% confidence interval [CI]: 0.687–0.782), outperforming qSOFA (AUC = 0.613), SI (AUC = 0.688), and GCS (AUC = 0.703)

P381 Prediction of readmission to ICU based on Japanese Intensive Care Patient Database by backward-elimination logistic regression with robust train/test pre-processing

A Ishii 1 , E Hashiba 2 , Y Sasaki 3 , H Endo 4 , K Noto 1 , J Saito 1

1 Hirosaki University Graduate School of Medicine, Department of Anesthesiology, Hirosaki, Japan, 2 Hirosaki University Hospital, Department of Intensive Care, Hirosaki, Japan, 3 Hirosaki University Hospital, Medical Informatics, Hirosaki, Japan, 4 Graduate School of Medicine, The University of Tokyo, Department of Healthcare Quality Assessment, Tokyo, Japan

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Introduction: Readmission to ICU (Re-ICU) during the same hospitalization causes health economic problems. There are no good predictive models for emergency Re-ICU in Japan. As nationwide ICU database, Japanese Intensive Care Patient Database (JIPAD) is now available, this study aimed to establish a logistic regression model to predict Re-ICU using a machine learning method.

Methods: The JIPAD records between 2018 and 2023 from 95 ICUs were used in this study. We identified single ICU admission (S-ICU) records without death or hospital transfer at ICU discharge and the first ICU admission records of emergency Re-ICU patients during same hospitalization. We investigated those patient’s characteristics and divided the dataset into 70% for predicting model training and 30% for the external model validation. Chi-square test, multivariable logistic regression analysis and a backward stepwise approach using the Python software with the scikit-learn library were employed to analyze. In order to establish the best prediction model 81 features like age, diagnosis, type of admission, patient's severity scores, chronic diseases, therapies in ICU and so on were included into the models.

Results: Among 325,844 records we identified 6,567 the first ICU admission record of emergency Re-ICU patients and 212,698 records of S-ICU patients. The hospital mortality rates of the emergency Re-ICU and S-ICU were 27.2% and 7.7%, respectively. We created the best prediction model using the training dataset with 42 features, which maximum AUROC was 0.73 (Figure). The AUROC of the model for the external validation was 0.72, suggesting appropriateness of the model. The positive features to the model were hematologic disease, digestive surgery, non-operative admission, emergency operation, SAPSII score and so on and the negative features were admission from emergency department, ICU admission after post resuscitation and so on.

Conclusions: Based on JIPAD, a good predictive model for emergency ICU readmission was established and validated.

Figure (abstract P381) Evolution of backward stepwise predictor selection using the AUROC. The process begins with a comprehensive model that incorporates all covariates. It then iteratively eliminates the least significant covariates one at a time until the model includes only a single covariate. The selection of covariates for removal at each step was determined by maximizing the mean validation area under the receiver operating characteristic curve (AUROC) obtained through 10 iterations of threefold cross)-validation

P383 The immunoglobulin-to-total protein ratio identifies distinct immune phenotypes and predicts outcomes in critically ill patients

YK Zhu, HY Xiong, B Wang, Y Kang

West China Hospital, Sichuan University, Department of Critical Care Medicine, Chengdu, China

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Introduction: The immune status of critically ill patients is a key determinant of prognosis, yet conventional measures of circulating immunoglobulins are confounded by both hemodilution and protein redistribution. The immunoglobulin-to-total protein (Ig/TP) ratio may provide a more accurate reflection of humoral immune competence than current measures. This study evaluated the prognostic value of the Ig/TP ratio among ICU patients.

Methods: Adult patients from the MIMIC-IV (v3.1) database with immunoglobulin and total protein data within 72 h of ICU admission available were included. Cox proportional hazards models were used to assess the predictors of 28- and 180-day mortality, followed by restricted cubic spline (RCS) analyses to characterize the nonlinear relationships between Ig/TP and outcomes. Subgroup analyses evaluated the consistency of associations across clinical strata, and random forest models were used to compare the predictive performance of different Ig/TP combinations.

Results: Among 645 patients, both IgA/TP and IgG/TP were significantly associated with mortality (Figure), whereas IgM/TP was not predictive. IgA/TP was associated with both 28-day and 180-day mortality: patients with either low or high ratios had a significantly greater risk of death than those in the intermediate range did. In contrast, the IgG/TP ratio had a weaker prognostic effect, affecting mainly long-term outcomes. The combined IgA/TP + IgG/TP model achieved the highest discrimination for both 28-day (AUC 0.825) and 180-day mortality (AUC 0.837), outperforming models based on absolute immunoglobulin concentrations.

Conclusions: The Ig/TP ratio, particularly the IgA/TP ratio, reliably stratifies immune phenotypes and predicts both short- and long-term mortality in critically ill patients. Combining IgA/TP and IgG/TP data increases prognostic accuracy. These findings may help explain the variable efficacy of IVIG and support Ig/TP-based profiling as a tool for personalized immunotherapy in the ICU.

Figure (abstract P383) Association of Ig/TP with 180-day mortality. (A and B) Dose–response relationships between (A) IgA/TP and (B) IgG/TP ratios and the adjusted hazard ratio for 180-day mortality, modeled using restricted cubic splines. (C and D) Kaplan–Meier survival curves depicting 180-day survival stratified by (C) IgA/TP and (D) IgG/TP thresholds derived from the restricted cubic spline model

P384 Revisiting organ failure in sepsis: incorporating immunologic markers into the SOFA concept in severe COVID-19

K Mattern 1 , J Grundmann 1 , O Moerer 1 , MS Winkler 1 , A Rau 1 , L Saager 1 , J Schanz 2 , B Tampe 3 , J Wieditz 4 , C Grimm 1

1 University Medical Center Göttingen, Department of Anesthesiology and Intensive Care Medicine, Göttingen, Germany, 2 University Medical Center Göttingen, Department of Hematology and Oncology, Göttingen, Germany, 3 University Medical Center Göttingen, Department of Nephrology and Rheumatology, Göttingen, Germany, 4 University Medical Center Göttingen, Department of Medical Statistics, Göttingen, Germany

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Introduction: COVID-19 represents a form of viral sepsis. Sepsis is diagnosed based on the presence of a pathogen and organ dysfunction, which is commonly assessed using the Sequential Organ Failure Assessment (SOFA) score [1]. However, the SOFA score does not include the underlying immune dysregulation that constitutes the central hallmark of sepsis. This study aimed to integrate laboratory and immunological parameters into an extended scoring concept (“iSOFA”) and to evaluate their prognostic relevance for survival in patients with severe COVID-19.

Methods: We retrospectively analyzed 207 ICU-treated patients with confirmed severe COVID-19. Conventional SOFA parameters were combined with immunological markers: CRP, D-dimers, ferritin, fibrinogen, IL-6, IL-2R, lactate, procalcitonin, leukocytes, and FACS-based lymphocyte subsets (CD3⁺, CD4⁺, CD8⁺, CD19⁺, CD3⁺/56⁺/16⁺). After multiple imputation (Rubin’s rules), stepwise forward logistic regression was applied, including SOFA in all models. Final analysis was performed on patients with complete data.

Results: Median age was 61 (50–71) years; the median SOFA score was 3 (2–4); 72% of patients were intubated and 37% received ECMO therapy. Overall mortality was 38%. In multivariable analysis, low CD19⁺ B-cells, CD4⁺ T cells, NK cells and CD8⁺ T cells, as well as elevated lactate levels were independently associated with mortality (Table). Area under ROC could be increased from 69.7%, 95%-CI [58.9–80.4] for a SOFA-only model to 89.2%, 95%-CI [82.7–95.6] for the “iSOFA” model.

Conclusions: Integrating immunological markers into the SOFA framework enhances risk stratification in COVID-19-associated sepsis. The iSOFA score represents a biologically informed extension of organ failure assessment, supporting a more holistic view of sepsis pathophysiology.

Reference Singer M et al. JAMA 2016;315:801–10

Table (abstract P384) Outcome relevant parameters– significant variables from the regression analysis

P385 SOFA 2.0 is superior to six scoring systems for predicting ICU mortality in sepsis patients: a multicenter retrospective data

X Luo, FR Lin, T Huang, JZ Zhang, AQ Lao, ZF Yang

Sun Yatsen Memorial Hospital, Sun Yatsen University, Intersive Care Unit, Guangzhou, China

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Introduction: Sepsis remains a life-threatening condition necessitating early identification of high-risk patients. Since conventional scoring systems show declining predictive performance over time, we evaluated the newly introduced SOFA 2.0 score against established prognostic models for predicting ICU mortality.

Methods: Patient data were extracted from the Sun Yat-sen Memorial Hospital (SYSMH), Medical Information Mart for Intensive Care IV version 3.1 (MIMIC-IV v3.1) and eICU Collaborative Research Database (eICU-CRD) (Figure). We calculated the sequential organ failure assessment (SOFA) 2.0 score based on its latest definition and compared against six assessment models (SOFA 1.0, Glasgow Coma Scale (GCS), systemic inflammatory response syndrome (SIRS), Oxford Acute Severity of Illness Score (OASIS), Charlson comorbidity index (Charlson). Discrimination, calibration, and clinical utility were evaluated using area under the receiver operating characteristic curve (AUROC), Youden index, decision curve analysis (DCA), calibration curves and multiple subgroup analyses.

Results: There were 871, 19028, and 7405 patients in the SYSMH, MIMIC-IV and eICU-CRD cohorts, respectively. In the internal database, the discrimination for ICU mortality with the SOFA 2.0 model was superior to the six traditional score of illness models, including SOFA, GCS, SIRS, OASIS, Charlson and APACHE II. Furthermore, SOFA 2.0 showed the largest reasonable risk threshold probability range, highest net benefit and Youden index, compared to traditional scoring systems models. Subgroup analysis and external cohorts yielded results consistent with the overall findings. Finally, an exploratory analysis confirmed that predictive model was improved when lactate was incorporated into the SOFA 2.0 score.

Conclusions: SOFA 2.0 demonstrated superior predictive capability of ICU mortality compared to traditional six models. We strongly recommend the early application of the SOFA 2.0 score in the intensive care unit.

Figure (abstract P385) Flow chart of study design of internal and external cohorts

P386 Prognostic value of the SOFA-2 score in emergency department patients with suspected sepsis: a multicenter prospective study

XX Xu 1 , YH Xu 1 , Q Zhong 1 , LT Jin 2 , RH Lin 1 , SW Jin 3 , ZH Zhang 4 , YP Jiang 1

1 Taizhou Hospital of Zhejiang Province, Department of Critical Care Medicine, Taizhou, China, 2 Taizhou Central Hospital Taizhou University Hospital, Department of Emergency Medicine, Taizhou, China, 3 The Second Affiliated Hospital and Yuying Children´s Hospital of Wenzhou Medical University, Department of Critical Care Medicine, Wenzhou, China, 4 Sir Run Run Shaw Hospital, Department of Emergency Medicine, Taizhou, China

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Introduction: Sepsis is a life-threatening condition in the emergency department (ED), making early and accurate assessment crucial. Although the updated SOFA-2 score performs well in the ICU, its value for ED patients with suspected sepsis is not well established [1].

Methods: We conducted a multicenter, prospective cohort study of patients with suspected sepsis admitted from the ED between May 2022 and August 2025. Clinical data and 28-day outcomes were recorded. We analyzed and compared the predictive value of SOFA-2, SOFA-1, qSOFA, and NEWS for 28-day mortality.

Results: Among 1,056 enrolled patients, the 28-day mortality rate was 15.34% (163/1056). The SOFA-2 score provided the best discrimination for mortality (AUROC: 0.744; 95% CI: 0.700–0.788) (Figure), significantly outperforming the other scores. Using an optimal cutoff of 7.5, SOFA-2 achieved a high negative predictive value of 91.2%. After multivariate adjustment, each 1-point increase in SOFA-2 was independently associated with an 18% higher risk of death (OR = 1.18, 95% CI: 1.13–1.24, p < 0.001).

Conclusions: The SOFA-2 score shows superior predictive accuracy for 28-day mortality in ED patients with suspected sepsis compared to other common scores. It is an effective tool for early risk stratification and can help guide clinical management.

Reference Ranzani OT et al. JAMA 2025;334:2090–2103

Figure (abstract P386) Distribution of SOFA-1 and SOFA-2 Scores across organ systems; Comparison of ROC Curves(A) and Comparison of diagnostic performance metrics(B) for SOFA-2, SOFA-1, qSOFA, and NEWS Scores

P387 Change of mean SOFA score to surrogate final outcome: a secondary analysis of the ImmunoSep trial

F Bloos 1 , K Leventogiannis 2 , C Nakou 3 , P Amoiridou 4 , A Flevari 5 , A Kosmidou 6 , G Nikolaidis 7 , A De Nooijer 8 , M Netea 9 , EJ Giamarellos Bourboulis 2

1 Jena University Hospital, Intensive Care Unit, Jena, Germany, 2 National and Kapodistrian University of Athens, 4th Department of Internal Medicine, Athens, Greece, 3 Ippokrateion General Hospital, Intensive Care Unit, Thessaloniki, Greece, 4 AHEPA University Hospital, Intensive Care Unit, Thessaloniki, Greece, 5 Sotiria Hospital, Polyvalent Intensive Care Unit, Athens, Greece, 6 Sotiria Hospital, Intensive Care Unit, Athens, Greece, 7 Asklipieion Hospital, Intensive Care Unit, Voula, Greece, 8 Radboud University Medical Center, Intensive Care Unit, Nijmegen, Netherlands, 9 Radboud University Medical Center, Department of Internal Medicine, Nijmegen, Netherlands.

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Introduction: The primary endpoint of the ImmunoSep trial ( NCT04990232 ) was the attainment of ≥ 1.4 points decrease of mean sequential organ failure assessment (SOFA) score by day 9 [1]. Selection of the primary endpoint was based on previous data from the VISEP [2] and MAXSEP [3] randomized clinical trials, which indicated that reduction of the mean SOFA by 1.4 points is associated with lower 28-day mortality among patients with severe sepsis. In this secondary analysis of the ImmunoSep trial, we assessed whether this primary endpoint could function as surrogate for 28-day mortality.

Methods: The primary efficacy endpoint of the ImmunoSep trial was calculated by subtracting the mean value of SOFA scores between days 2 and 9 from baseline score of day 1. Participants achieving a reduction of ≥ 1.4 points were classified as achievers, all others as non-achievers. For this secondary analysis, 28-day mortality was compared between achievers and non-achievers. Comparison was conducted using Fisher’s exact test; odds ratio (OR) and 95% confidence interval (CI) were calculated according to Mantel and Haenszel.

Results: A total of 276 participants were analysed in the primary population analysis, all of whom were included in this secondary analysis. Eight of 72 achievers (11.1%) died by day 28 compared to 121 of 204 non-achievers (59.3%) of the primary endpoint (Figure).

Conclusions: Decrease of mean SOFA score of at least 1.4-points effectively served as surrogate for 28-day mortality in the ImmunoSep trial. Further studies are necessary to validate whether this surrogate endpoint can reliably replace 28-day mortality in future pilot clinical trials.

References Kotsaki A et al. BMJ Open 2022;12:e067251 Brunkhorst FM et al. N Engl J Med 2008;358:125–139 Brunkhorst FM et al. JAMA 2012;307:2390–2399

Figure (abstract P387) Comparison of 28-day mortality between achievers and non-achievers of the primary endpoint

P389 SAPS 3 evaluation in two high dependency units – performance analysis and prognostic value

P Bonazza 1 , E Sellin Bredberg 2 , M Nilsson 3

1 Karolinska University Hospital, Acute and Reparative Medicine, Stockholm, Sweden, 2 Karolinska Institutet, Stockholm, Sweden, 3 Karolinska Institutet, Department of Medicine, Solna, Stockholm, Sweden

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Introduction: High dependency units (HDUs) care for patients with acute or impending organ dysfunction who require close monitoring but not full intensive care. As ICU capacity remains limited, HDUs play an increasingly important role, yet validated prognostic tools tailored to this setting are scarce. The Simplified Acute Physiology Score 3 (SAPS-3) is widely used in ICUs, but its performance in Swedish HDUs is unknown. Since the Swedish Intensive Care Registry (SIR) recalibrated SAPS-3 for Swedish ICUs [1], the model may better reflect mortality risk in Swedish critical-care environments, making evaluation in HDUs relevant. Our aim was to assess the ability of SAPS-3 to predict 30-day mortality in patients admitted to two HDUs at a tertiary university hospital.

Methods: Retrospective cohort study including 265 adults admitted to two medical HDUs at Karolinska University Hospital in 2024. SAPS-3 was calculated from admission data. Discrimination was evaluated using AUC, calibration using SMR, and multivariable logistic regression assessed the independent association between SAPS-3 and mortality.

Results: Mean SAPS-3 was 53.0 ± 14.0. Observed 30-day mortality was 18.1% vs. a predicted 15.9% (SMR 1.14). SAPS-3 demonstrated strong discrimination (AUC 0.854, 95% CI 0.802–0.906). Each one-point increase in SAPS-3 corresponded to a 10% increase in mortality risk (OR 1.10, p < 0.001). A “No ICU” treatment-restriction order was also associated with higher mortality (OR 3.86, p < 0.01).

Conclusions: SAPS-3 showed good predictive performance for HDU patients, comparable to results from ICU cohorts. The acceptable calibration may partly reflect the SIR recalibration of SAPS-3 for Swedish practice. These findings support SAPS-3 as a useful risk-stratification tool in HDUs. Larger multicentre studies are needed to confirm generalizability and evaluate whether further calibration is required.

Reference Risk adjustment models in Swedish intensive care – Swedish Intensive Care Register SIR- https://tinyurl.com/fokusrapport-riskjustering-Sir

P390 Centralized management panel for stratifying the severity of bronchiolitis and sepsis in a pediatric ICU

N Arguedas 1 , A Felipe 1 , A Solé 1 , E Esteban 1 , I Jordán 1 , R Casadevall 2 , J Gibert 3 , F García 3 , O Rodríguez 1 , FJ Cambra 1

1 Hospital Sant Joan de Déu, Pediatric Intensive Care Unit PICU, Esplugues de Llobregat, Spain, 2 Hospital Sant Joan de Déu, Healthcare Management Support Unit, Esplugues de Llobregat, Spain, 3 Hospital Sant Joan de Déu, Data and Digital Strategy Unit, Esplugues de Llobregat, Spain

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Introduction: In pediatric intensive care units (PICU), bronchiolitis and sepsis are relevant due to their high incidence and the difficulty of predicting their clinical course. At Sant Joan de Déu Hospital, have been developed and validated two severity scoring systems: BROSJOD for bronchiolitis and PESERS for sepsis [1, 2]. Both scores are reliable tools for diagnosis and severity classification.

Methods: To implement centralized management, patient data streams from hospital information systems were integrated through queries that enabled near real-time visualization. Risk scores are generated automatically and updated every 5 min through algorithms that track key clinical metrics. The system uses the Denodo platform to create and refresh dynamic views, which are then displayed in Tableau, giving clinicians a clear and actionable overview of patient status and evolving risk. This dashboard is embedded within a centralized monitoring framework, both in the PICU and in the Clinical Command Center [3].

Results: A data ecosystem was created, resulting in a centralized management dashboard with real-time updates (Figure).

Conclusions: The dashboard aims to provide early warnings of patient deterioration and to support clinical decision-making by offering an integrated, continuously updated view of bronchiolitis severity and the early diagnosis and stratification of sepsis, ultimately improving care quality and outcomes for critically ill children.

References Solé-Ribalta et al. Acta Paediatr 2022;111:1209–1219 Balaguer M et al. Pediatr Pulmonol 2017;52:533–539 The Lancet Digital Health. Lancet Digit Health 2019;1:e1

Figure (abstract P390) Centralized management panel (dashboard)

P391 Enhancing ICU information delivery: integrating analog with digital approaches

L Lim 1 , C Kang 2 , H Lee 1 , HG Ryu 2 , SY Oh 2

1 Seoul National University Hospital, Department of Anesthesiology and Pain Medicine, Seoul, South Korea, 2 Seoul National University Hospital, Department of Critical Care Medicine, Seoul, South Korea

Critical Care 2026, 30 (Suppl 1): P391

Introduction: Caregivers of critically ill patients often experience significant distress, partly due to insufficient or poorly accessible information. While digital information delivery such as web-based mobile video has become standard, particularly after COVID-19, concerns exist about accessibility and the digital divide. We hypothesized that supplementing mobile-based video education with a physical leaflet would enhance caregiver satisfaction with ICU information.

Methods: We conducted a single-center, pre–post implementation study in a surgical intensive care unit (ICU). During the pre-implementation phase (July–August 2023), caregivers received a mobile video explaining the ICU environment, visiting policies, and care processes. During the post-implementation phase (September 2023–February 2024), a physical leaflet summarizing the same key information was provided in addition to the video. To evaluate information satisfaction, caregivers completed System Usability Scale (SUS) at discharge. The primary outcome was SUS total score; secondary outcomes included usability, learnability, and perception of appropriateness and timeliness.

Results: Among 143 caregivers (video only: n = 60; video + leaflet: n = 83), baseline characteristics were similar between groups. SUS total scores were higher when the leaflet was added to the video (77.5 [67.5–86.2]) compared with video alone (65.0 [57.5–80.8]), as were usability (78.1 vs. 65.6) and learnability (75.0 vs. 62.5), as shown in the Table. A greater proportion of caregivers agreed that the information provided was appropriate and timeliness ratings.

Conclusions: Supplementing mobile-based video with a physical leaflet significantly improved caregiver satisfaction with ICU information compared with video alone. Integrating analog and digital approaches may better address diverse caregiver needs and enhance communication quality in critical care settings.

Table (abstract P391) Satisfaction and perception on provided information

P393 Improving continuity of care: audit of discharge summaries and follow-up for bisoprolol and amiodarone started in ICU

S Harvey, A Krishan, M Rich, J Small, U Watson, B.J Philips

University Hospitals Sussex NHS Foundation Trust, Intensive Care Unit, Brighton, UK

Critical Care 2026, 30 (Suppl 1): P393

Introduction: Medications are often started in Intensive Care to manage rapidly evolving complications of critical illness. Bisoprolol and amiodarone are commonly used for arrhythmias, yet continuation after ICU is not always necessary and may cause harm [1]. Both require clear documentation and planned follow-up. We examined why these medications were initiated, the quality of discharge documentation, and whether follow-up was adequate.

Methods: We audited ICU patients discharged between Oct 2024 and Oct 2025 with new bisoprolol or amiodarone prescriptions. ICU and hospital discharge summaries were reviewed for documentation of the medication, indication, and planned follow-up. Documentation was compared with NICE guidelines [2]. Patients who died in ICU or lacked accessible documents were excluded.

Results: 83 patients (26 women, mean age 66) were discharged with new bisoprolol prescriptions; discharge documentation is summarised below (Figure). 34/83 ICU discharge summaries did not highlight the new medication and indication, and only 5/83 ICU discharge summaries documented ideal discontinuation plans on ward stepdown. 3 patients (1 woman, mean age 80) were discharged on newly initiated amiodarone. 2/3 ICU discharge summaries did not highlight the new medication and indication; follow-up plans were absent. Only one patient continued amiodarone after hospital discharge, with appropriate review arranged.

Conclusions: The audit highlights major gaps in documenting ICU-initiated medications and planning follow-up. In response, we are delivering targeted education and updating the discharge summary template to prompt clearer recording. Improved collaboration with the ICU rehabilitation team may further support safer transitions of care and improved long-term medication management.

References Rossello X et al. Eur Heart J 2025; ehaf673 NICE. www.nice.org.uk/CG050 . Clinical Guideline 50, 2007

Figure (abstract P393) Documentation and discharge outcomes for new bisoprolol initiated in ICU

P394 The impact of ICU follow-up: identifying ongoing needs six months after discharge

I Quinteiro 1 , C Cerca 1 , M Cardoso Costa 2 , A Balbino 1 , AF Monteiro 1 , S Galhano 1 , A Valente Santos 1 , L Bento 1

1 Unidade Local de Saúde de São José, Unidade de Urgência Médica, Lisboa, Portugal, 2 Unidade Local de Saúde de São José, CRECMO, Lisboa, Portugal

Critical Care 2026, 30 (Suppl 1): P394

Introduction: Follow-up after ICU discharge enables early detection of post-intensive care syndrome (PICS) and timely referral to specialists when long-term problems are identified. This study aims to assess the effectiveness of a structured ICU follow-up program in detecting ongoing health concerns and facilitating access to multidisciplinary care.

Methods: We performed a retrospective analysis of patients attending the ICU follow-up clinic of a tertiary hospital between January and December 2024. Appointments occurred 6 months after ICU discharge, either in person or via videocall. Patients with an ICU stay shorter than 48 h were excluded. Data on physical, cognitive, and psychological outcomes were collected using validated questionnaires and clinical assessments.

Results: Among 855 ICU admissions, 399 patients met eligibility criteria; 364 had stays under 48 h, and 92 died in the ICU. Of eligible patients, 107 (29.3%) attended the appointment—64 men (59.8%) and 43 women (40.2%), with a mean age of 53.0 ± 17.5 years, and an average ICU stay of 11.0 ± 9.3 days. Six months after ICU discharge, patients scored 92.7 ± 19.0 on the Barthel Index, 70.3 ± 20.0 on the EQ-5D, 4.5 ± 4.8 on the HADS, and 10.4 ± 11.4 on the PTSS-10. Thirty-seven patients (34.6%) were referred to additional specialties due to symptoms identified during screening or missed follow-up, most commonly Psychology and Pulmonology.

Conclusions: In our cohort, ICU follow-up had a significant impact on long-term care, serving as a safety net for complex patients by addressing all dimensions of PICS and facilitating specialist referrals. In 35% of patients, follow-up resulted in referral to an appropriate specialty for further assessment. These results led to restructuring follow-up pathways for selected patient groups in our centre.

P395 A qualitative analysis of coping types among ICU survivors with chronic intensive care related pain

G Laporte, BA EbobAnya, C Gélinas

McGill University, Ingram School of Nursing, Montreal, Canada

Critical Care 2026, 30 (Suppl 1): P395

Introduction: In Canada, one in three intensive care (ICU) survivors develops chronic pain [1] that can interfere with daily functioning and affect quality of life [2]. In ICU survivors, the role of coping in the progression and management of chronic ICU-related pain (CIRP) remains poorly understood. Our study aimed to propose a typology of coping types based on qualitative interviews.

Methods: According to the qualitative typology method developed by Gerhardt and Weber [3], we established a typology of coping styles based on interviews conducted with ICU survivors who experienced pain > 3/10 three months after discharge. Interview questions focused on the challenges, preferences, and perceived effectiveness of the coping strategies they used. We wrote individual case summaries and regrouped ICU survivors who adopted a similar coping style. We drafted a general description of each case grouping, which was identified by a representative label.

Results: We conducted interviews with 23 ICU survivors over 24 months. Participants were mostly men (n = 15), aged 25 to 85 years old (mean = 56). They had spent between 3 and 65 days in the ICU (mean = 12). Most had been admitted for surgical reasons (n = 14), and experienced pain ranging from 3 to 8 (mean = 6) at 3 months post-ICU. Our typology uncovered four coping types among these ICU survivors, based on two main traits: independence and proactivity. Most of our participants (n = 11) were categorized as social-proactive or independent-proactive (n = 4) types. The remaining participants were classified as independent-detached (n = 5) or social-detached (n = 3) types.

Conclusions: Our results indicate ICU survivors can show different coping styles when faced with chronic pain. Future studies should explore the relationship between coping types and health outcomes post-ICU.

References Canadian Pain Task Force Report (2020) Mäkinen OJ et al. Br J Anaesth 2020;125:149–58 Stapley E et al. Int J Qual Methods 2022;21: 10.1177/16094069221100633

P396 The impact of social connectivity on ICU survivor and family recovery

S Tang 1 , JY Kung 2 , V Kalinin 1 , S Tymchuk 3 , L Carayannopoulos 4 , ME Wilcox 1

1 University of Alberta, Department of Critical Care Medicine, Edmonton, Canada, 2 University of Alberta, Geoffrey Robyn Sperber Health Sciences Library, Edmonton, Canada, 3 University of Alberta, Department of Psychiatry, Edmonton, Canada, 4 McMaster University, Department of Medicine, Hamilton, Canada

Critical Care 2026, 30 (Suppl 1): P396

Introduction: This study investigates the effects of social connectivity on ICU survivors and their families. Social support has positive impacts on health outcomes in many populations. With rising rates of ICU survivorship, optimization of follow-up care is increasingly important. ICU survivors and their families often experience enduring symptoms impacting physical, psychological and cognitive aspects of their lives [1]. This is described as post-intensive care syndrome (PICS) or post-intensive care syndrome-family (PICS-F).

Methods: The PRISMA-ScR [2] and Joanna Briggs Institute [3] guidelines were used to structure this scoping review. We searched MEDLINE, EMBASE, CINAHL, and PsychInfo, grey literature, and the first 200 Google Scholar results. Our population of interest was adult ICU survivors and their families or caregivers. We included all research except reviews and case reports. Abstracts and full texts were assessed by two independent reviewers, and qualitative data was collected and analyzed.

Results: Our analysis included 37 full texts. ICU survivors required 6–12 months of recovery to regain physical function, measured by SF-36 scores, walk tests and spirometry. Those with more social supports reported subjective improved physical recovery. ICU families and caregivers experienced fewer depressive symptoms and improved quality of life with social support, but anxiety was often found to be unrelated to social supports.

Conclusions: Social connectivity can provide benefit in the recovery of physical function, mental health symptoms, and overall quality of life in ICU survivors and their families. Further research will be required to elucidate the most effective ways to improve social connectivity and recovery, and to quantify the impact of organized support groups.

References Falvey JR et al. JAMA Intern Med 2021;181:1433–1439 Tricco AC et al. Ann Intern Med 2018;169:467–473 Jordan Z et al. JBI Evid Implement 2018;16:227

P397 Association of frailty identified by a population-level frailty index and long-term ICU patient outcomes

Q Li 1 , D Nassim 1 , H Dahel 2 , D Williamson 3 , S Chagnon 4 , JP Bluteau 4 , J Rinfret 5 , J Beaucage-Charron 5 , JP Emond 6 , HT Wang 7

1 University of Montreal, Faculty of Medicine, Montreal, Canada, 2 University of Montreal, Faculty of Pharmacy, Montreal, Canada, 3 Centre Intégré Universitaire de Santé et de Services Sociaux du Norddel´Île de Montréal, SacréCoeur Hospital, Montreal, Canada, 4 Centre Intégré Universitaire de Santé et de Services Sociaux de l´Estdel´Île de Montréal, Montreal, Canada, 5 Maisonneuve-Rosemont Hospital, Department of Pharmacy, Montreal, Canada, 6 University of Laval, Division of Geriatric Medicine, Quebec, Canada, 7 Centre Hospitalier de l´Université de Montréal, Division of Critical Care, Montreal, Canada

Critical Care 2026, 30 (Suppl 1): P397

Introduction: Frailty is a multidimensional state of reduced physiological reserve associated with increased vulnerability to acute stressors, including critical illness. Frail ICU patients experience more adverse outcomes [1], but few studies have examined their long-term outcomes. Our objective was to assess the association between frailty and long-term ICU outcomes, including 1-year mortality and health resource use, using a Frailty Index (FI) derived from medico-administrative data.

Methods: We identified adults admitted between 2015–2023 to the ICUs of two hospitals in Quebec (Canada). Clinical information was extracted from medico-administrative databases (hospital discharge summaries, home care records, in-hospital medication data). A 30-item Frailty Index (FI) was created across comorbidity, cognitive, functional, psychosocial, and socioeconomic domains [2]. Frailty was defined as FI ≥ 0.20 [2]. Outcomes at 3 months and 1 year were compared using descriptive analyses and multivariable logistic regression adjusted for age, sex, dialysis, mechanical ventilation, admission year, and hospital site.

Results: Among 10,857 patients, 23% were frail and 8871 patients survived initial hospitalization. Frailty was associated with higher 3-month mortality (11.5% vs 4.7%, p < 0.001) and 1-year mortality (26.7% vs 10.4%, p < 0.001) (Table). Frail patients had more 1-year hospitalizations (45.9% vs 23.1%, p < 0.001) and ED visits (43.1% vs 30%, p = 0.050). Frailty strongly predicted 1-year mortality (aOR 2.51, 95% CI 2.18–2.88). Mechanical ventilation (aOR 1.43, 95% CI 1.23–1.65) and dialysis and (aOR 1.75, 95% CI 1.33–2.29) also increased risk.

Conclusions: Our 30-item Frailty Index independently predicted 1-year mortality and was associated with greater post-ICU healthcare use.

References Bagshaw SM et al. CMAJ 2014;186:E95-E102 Rockwood K et al. CMAJ 2005;173:489–95

Table (abstract P397) Long term mortality and heath resource use

P398 The importance of frailty, and anticipating post intensive care syndrome

LG Élo 1 , O Szucs 2 , E Benkovics 1 , Z Molnár 1 , G Élö 1 , L Zubek 1

1 Semmelweis University, Department of Intensive Therapy, Budapest, Hungary, 2 Semmelweis University, Department of Surgery, Transplantation and Gastroenterology, Budapest, Hungary

Critical Care 2026, 30 (Suppl 1): P398

Introduction: We have conducted a single-centre prospective observational study at the Semmelweis University Department of Intensive Therapy. We focused on post-intensive care syndrome (PICS), quality of life, and their correlation with frailty and acute illness severity at admission.

Methods: We conducted our study on 245 patients at two ICUs in our department, with diverse aetiologies and pre-hospitalisation histories. Exclusion criteria were death or discharge before 24 h of ICU care. At admission, we recorded the Clinical Frailty Scale (CFS), APACHE II, and SAPS II scores. At 3 months after discharge, EuroQoL 5D5L was collected via telephone interview among 103 of 112 survivors. At 12 months, EQ-5D, SF-36 QoL survey, MMS, and Beck Depression Inventory were collected during a personal interview, with 45 respondents out of 97 survivors.

Results: Compared with validated population studies of Hungary [1], our patients have shown below-average scores in General Health, Physical Role Impairment, and Mental Health. We observed above-average scores in Bodily Pain, Social Functioning, Vitality and Emotional Role Impairment dimensions. The average EQ5D index was 0.92 at 3 months and 0.84 at 12 months. MMS test showed no cognitive impairment. U tests suggested a strong correlation between Physical Functioning and CFS, General Health and APACHE/SAPS-II. Pain, Social Function, Emotional Role Impairment and EQ5D correlated with all three. ROC analysis has shown AUC > 0.7 for CFS and Physical functioning, as well as the one-year EQ5D index.

Conclusions: Contrary to the established literature [2], we have observed that our patients' long-term QoL is not significantly worse than that of the general population and that there is a strong statistical correlation between frailty and acute illness severity at admission and eventual QoL. We have failed to show a significant predictive value for any of the parameters monitored at admission, for eventual QoL.

References Inotai A et al. Qual Life Res 2024;33:2417–2428 Gerth AMJ et al. Anaesthesia 2019;74:100–108

P399 Quality of dying and death in a Korean surgical ICU: a comparative analysis of physician and nurse perceptions

YCJ Jeong 1 , HL Lee 2

1 Seoul National University Hospital, Critical Care Medicine, Seoul, South Korea, 2 Seoul National University Hospital, Anesthesiology and Pain medicine, Seoul, South Korea

Critical Care 2026, 30 (Suppl 1): P399

Introduction: Given the differences in intensive care unit (ICU) settings, few studies have looked at how medical staff view death in surgical ICUs. This research aims to address this gap by studying how medical personnel, mainly in surgical ICUs, view and understand death. These insights are crucial for raising the quality of care for patients at the end-of-life.

Methods: A preliminary prospective study was carried out between June 2023 to October 2025. Physicians and nursing staff directly involved in the care of patients who had passed away were invited to complete the Quality of Dying and Death (QODD) survey within two days following the patient’s demise. The 20-item QODD instrument yields a total score from 0 to 100, with higher scores indicating a better end-of-life experience.

Results: Analysis of 143 questionnaires from 58 ICU staff (22 doctors, 36 nurses) caring for 49 deceased patients showed doctors reported higher QODD scores than nurses (23.8 ± 9.4 vs. 19.4 ± 9.3; p = 0.007). Doctors significantly experienced more death than nurses (r = -0.48, p < 0.01) but received less education about death (r = 0.59, p < 0.01). Discussions about patient wishes and applying appropriate sedation correlated positively with better death quality, respectively (r = 0.78, p < 0.01; r = 0.65, p = 0.01). Additional findings revealed that despite advanced care planning and end-of-life decision documentation (85.7%), 16.3% received cardiopulmonary resuscitation within 24 h before death. Despite low prevalence on use of sedatives and analgesics (53.1% and 65.3%), low GCS seem to give the impression of appropriate sedation.

Conclusions: In the present study, physicians and nurses in surgical ICUs reported substantially lower quality of dying and death scores for their patients compared with those typically observed in medical ICUs. Our findings underscore the necessity of more consistent advance care planning to elevate the standard of end-of-life care for patients and their healthcare providers.

P400 Postoperative persistent inflammation, immunosuppression, and catabolism syndrome (PIICS): incidence and outcomes after major surgery

K Sasaki 1 , K Tojo 2 , T Mihara 1

1 Department of Health Data Science, Graduate School of Data Science, Yokohama City University, Yokohama, Japan, 2 Department of Anesthesiology, Yokohama City University School of Medicine, Yokohama, Japan

Critical Care 2026, 30 (Suppl 1): P400

Introduction: Persistent Inflammation, Immunosuppression, and Catabolism Syndrome (PIICS) has been described as a chronic critical condition characterized by sustained inflammatory and immune dysregulation [1]. Although PIICS has primarily been studied in critically ill patients, major surgery also imposes substantial physiological stress, yet whether PIICS occurs in surgical patients and affects their outcomes remains unknown. We therefore aimed to determine the incidence, clinical characteristics, and mortality impact of PIICS after major surgery.

Methods: We conducted a retrospective observational study including 18,137 adults undergoing major surgery lasting > 2 h. PIICS was defined around postoperative day 14 when all of the following criteria were met: C-reactive protein > 3.0 mg/dL, albumin < 3.0 g/dL, and lymphocyte count < 800/μL [1]. We compared in-hospital mortality and clinical characteristics between PIICS and non-PIICS groups and estimated the adjusted association between PIICS and mortality using multivariable logistic regression.

Results: PIICS occurred in 3.2% of surgical patients. Compared with non-PIICS patients, those with PIICS were older, more often male, and had lower BMI, longer operative duration, and greater blood loss. In-hospital mortality was markedly higher in the PIICS group (6.6% vs. 0.2%). After adjustment for demographic and clinical covariates, PIICS remained strongly associated with in-hospital mortality (adjusted odds ratio 18.8, 95% CI 10.7–33.5, p < 0.001).

Conclusions: PIICS was strongly associated with in-hospital mortality in surgical patients. These findings suggest that PIICS represents a clinically important postoperative phenotype, highlighting the need to elucidate its underlying immune–metabolic mechanisms and to develop approaches for early recognition and prevention.

Reference Chadda KR et al. Br J Anaesth 2024;132:507–18

P401 Functional reserve in sepsis survivorship: a missing construct in critical care recovery

SW Radies 1 , S Bradwell 2 , J Gelinas 2 , G Nonis 1 , N Eves 3 , J Boyd 4 , G Koelwyn 2

1 University of British Columbia, Medicine, Vancouver, Canada, 2 Centre for Heart Lung Innovation, Exercise Physiology, Vancouver, Canada, 3 University of British Columbia, School of Health and Exercise Sciences, Vancouver, Canada, 4 University of British Columbia, Critical Care Medicine, Vancouver, Canada

Critical Care 2026, 30 (Suppl 1): P401

Introduction: There is a growing call to action concerning post-sepsis morbidity. To date, impairments in physical functioning following sepsis have been conceptualized in terms of reduced functional capacity. This construct misses a crucial point: not only is maximal capacity decreased, resting demands also increase. The overall effect is a loss of functional reserve needed to perform basic activities and adapt to rehabilitation stimuli. We contend that functional reserve is a novel framework to guide optimized interventions and improve patient outcomes following sepsis.

Methods: We conducted a targeted synthesis of literature describing energetic disturbances and recovery trajectories in sepsis, including studies of indirect calorimetry, cardiopulmonary exercise testing (CPET), organ-specific dysfunction, and ICU and post-ICU rehabilitation interventions.

Results: Sepsis triggers a precipitous loss of functional reserve, driven by its pathology, treatment effects, and host risk factors (Figure). Following sepsis, functional capacity is 30–50% below age-matched norms, persisting up to 5 years post diagnosis [1, 2]. Further, resting energetic demands increase through ICU stay and remain elevated post-discharge [3]. As a result, the metabolic cost of basic activities may become unmanageable for patients.

Conclusions: The prognostic significance of functional reserve dynamics is currently underexplored in sepsis survivorship. Although functional capacity is the gold-standard outcome in rehabilitation protocols, it may be an inappropriate initial target in the context of profoundly reduced functional reserve. We recommend rehabilitation protocols that decrease the demand of sub-maximal exercise, widen the adaptive window, and incrementally introduce system stress in a patient-specific manner.

References Borges RC et al. Intensive Care Med 2015;41:1433–1444 Van Aerde N et al. Intensive Care Med 2021;47:1462–1471 Moonen HPFX et al. J Crit Care 2023;78:154,361

Figure (abstract P401) The pleotropic biological mechanisms driving decline in functional reserve in sepsis survivorship

P402 Association between abnormal DNA methylation and altered transcriptome in muscle five years after critical illness

C Uzun Ayar 1 , F Güiza 2 , I Derese 1 , G Van den Berghe 2 , I Vanhorebeek 1

1 KU Leuven, Laboratory of Intensive Care Medicine, Leuven, Belgium, 2 KU Leuven, Clinical Division and Laboratory of Intensive Care Medicine, Leuven, Belgium

Critical Care 2026, 30 (Suppl 1): P402

Introduction: Critically ill patients admitted to the intensive care unit (ICU) suffer from persisting muscle weakness for years. We documented altered RNA expression in muscle 5-years post-ICU, indicating impaired mitochondrial function, disrupted lipid metabolism, and fibrosis, which associated with lower long-term muscle strength [1]. We hypothesized that abnormal DNA methylation may provide a biological basis for this long-term altered muscle transcriptome and weakness.

Methods: Genome-wide DNA methylation was analyzed in muscle of 118 former ICU patients and 30 controls. Differentially methylated positions (DMPs) in former ICU patients versus controls were identified, followed by pathway overrepresentation of affected RNAs. DMP methylations were correlated with RNA expressions. Risk factors for abnormal DNA methylation were evaluated with multivariable linear regression.

Results: Former ICU patients showed 7379 DMPs (average methylation difference 2.6% ranging up to 24.9%), associated with 1334 unique genes, enriched for muscle contraction, vascular development, cell differentiation and signal transduction. DMPs correlated more strongly with differentially expressed RNAs (DERNAs) than with non-DERNAs (18.1% vs 1.7% correlations with |rho|> 0.3). Such correlations were more abundant among DERNAs associated with reduced muscle strength vs those not associated (24.4% vs 12.5%), also within the previously identified disrupted pathways (mitochondrial function 23.3% vs 10.9%, lipid metabolism 15.9% vs 7.2%, fibrosis 44.3% vs 5.8%). Several potentially avoidable in-ICU treatments were associated with more abnormal DNA methylation, most notably glucocorticoids, benzodiazepines and early parenteral nutrition.

Conclusions: Abnormal DNA methylation in muscle 5 years post-ICU, partly attributable to possibly avoidable risk factors, associated with abnormal RNA expression related to lower long-term muscle strength.

Reference Uzun Ayar et al. Intensive Care Med 2025;51:1062–77

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