Acute and Critical Care

Original Articles

Anesthesiology
Ultrasound-guided supraclavicular internal jugular vein compression to increase internal jugular vein cross-sectional area in hospitalized patients: a prospective observational study in Japan: Masataka Hiruma, Hiroyuki Honda, Shuichiro Kurita, Shunsuke Nukaga, Mitsuhiro Watanabe, Kei Nishiyama; Acute Crit Care. 2025;40(4):574-581. Published online November 24, 2025; DOI: https://doi.org/10.4266/acc.002025

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Abstract PDF: Background
Real-time ultrasound-guided catheterization of the internal jugular vein (IJV) is widely used for its safety and high success rate. However, it becomes difficult when the IJV’s cross-sectional area (CSA) is reduced. A reported technique applies manual pressure (with fingers) to the supraclavicular IJV to impede venous return and enlarge the distal CSA. While effective in previous studies, its clinical utility remains unclear, as those studies involved only healthy volunteers and used blind technique. Therefore, this study aimed to evaluate the efficacy of our novel ultrasound-guided compression of the proximal IJV.
Methods
In this prospective observational study, 25 hospitalized patients were included. Two ultrasound machines were used: one to visualize the CSA of the distal IJV, and the other to apply and guide compression of the supraclavicular IJV, ensuring real-time confirmation of venous occlusion. Patients were asked about pain during the compression procedure. The primary outcome was the degree of dilation at the puncture site of the IJV.
Results
All 25 patients (mean Sequential Organ Failure Assessment score: 5.2±3.6) completed the study. Supraclavicular IJV compression resulted in a significant increase in the CSA of the distal IJV by approximately 150%, from 0.4±0.3 cm² to 1.0±0.3 cm² (P<0.001). No patient reported any pain during the procedure.
Conclusions
Ultrasound-guided supraclavicular IJV compression significantly increased the CSA of the distal IJV in hospitalized patients. This method enhances vein visibility by increasing IJV volume, potentially improving the success and safety of central venous catheterization.

Cardiology
Thoracic fluid content by electrical cardiometry versus diaphragmatic excursion by ultrasound for the prediction of weaning success in patients with lung congestion: Shawky Meselhy Elshaer, Ahmed Mostafa Abdelhamid, Enas Wageh Mahdy, Samar Rafik Amin; Acute Crit Care. 2025;40(4):557-566. Published online October 15, 2025; DOI: https://doi.org/10.4266/acc.003984

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Abstract PDF: Background
Predicting the weaning outcomes is critical, since premature or delayed extubation is associated with an increased risk of mortality. This study aimed to compare two physiological indices, thoracic fluid content (TFC) and diaphragmatic excursion (DE), for predicting weaning success in mechanically ventilated patients.
Methods
This observational cohort study involved 100 mechanically ventilated patients with congested lungs who were eligible for weaning. Patients’ TFC and DE were measured using electrical cardiometry and ultrasonography, respectively, before starting the spontaneous breathing trial. Following extubation, patients were grouped into successful and failed-weaning groups, with failure defined as reintubation or a need for non-invasive ventilation within 48 hours. Respiratory and cardiovascular variables were compared. The receiver operating characteristic (ROC) curve was used to assess the ability of TFC and DE to predict weaning success.
Results
Successful weaning occurred in 73 patients (73%) and failed weaning occurred in 27 patients (27%). The two groups’ baseline characteristics were comparable; however, TFC and DE were significantly different between the failed- and successful-weaning groups (P<0.001). The area under the ROC curve (AUC) exhibited moderate predictive abilities of both the TFC and DE in predicting weaning success (AUC, 0.805, cutoff <40 kΩ−1 and AUC, 0.774, cutoff >1.45 cm). In the cardiac patient subgroup, TFC exhibited high predictive ability (AUC, 0.861), but DE did not achieve comparable results (AUC, 0.750).
Conclusions
Both TFC and DE are significant predictors for successful weaning from mechanical ventilators. In particular, a TFC of <40 kΩ−1 demonstrated an excellent ability to predict weaning success in patients with low ejection fraction.

Review Article

Nutrition
Intensive care unit-acquired muscle atrophy and weakness in critical illness: a review of long-term recovery strategies: Nobuto Nakanishi; Acute Crit Care. 2025;40(3):361-372. Published online August 29, 2025; DOI: https://doi.org/10.4266/acc.001450

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Abstract PDF: Intensive care unit (ICU)-acquired muscle atrophy and weakness are key contributors to post-intensive care syndrome (PICS), which can lead to long-term functional impairments. Although the ICU survival rate has improved, many patients continue to experience persistent functional impairments that hinder their reintegration into society. This review summarizes a series of observational and interventional studies conducted as part of the Muscle Atrophy Zero Project, focusing on the etiology, assessment, and prevention of ICU-acquired muscle atrophy and weakness. The project findings highlight the critical role of inflammation, particularly neutrophil infiltration, in the pathogenesis of muscle atrophy. Muscle damage can be assessed using ultrasound, bioelectrical impedance analysis, and urinary titin. Among them, ultrasound demonstrates high diagnostic accuracy for detecting low muscularity, and urinary titin has emerged as a promising biomarker of muscle degradation. Preventive strategies include early rehabilitation, neuromuscular electrical stimulation, vibration therapy, and nutritional support, especially protein supplementation. These multimodal interventions have shown efficacy in mitigating ICU-acquired muscle atrophy and weakness. However, follow-up systems for PICS remain underdeveloped. A continual multimodal intervention approach that combines physical rehabilitation with nutritional therapy is essential. The development of structured follow-up programs is vitally needed to confront the long-term challenges posed by PICS.

Original Articles

Cardiology
Diaphragm ultrasound for predicting weaning success in post-cardiac surgery acute respiratory distress syndrome patients: a prospective observational study in China: Yuan-Qin Huang, Pei Yu, Dou-Dou Xiang, Quan Gan; Acute Crit Care. 2025;40(3):435-443. Published online August 21, 2025; DOI: https://doi.org/10.4266/acc.004320

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Abstract PDF: Background
To explore the value of the diaphragm thickness fraction (TF) and diaphragm mobility (DM) measured by ultrasound for predicting ventilator withdrawal success in patients with acute respiratory distress syndrome (ARDS) after cardiac surgery. Methods: This study included 246 patients undergoing the spontaneous breathing trial. Diaphragmatic function was evaluated by ultrasound, including the diaphragm thickness at the end of calm breathing (thickness of the diaphragm at functional residual capacity [TdiFRC]) and the maximum diaphragm thickness at the end of inspiration (thickness of the diaphragm at full vital capacity [TdiFVC]); TF=(TdiFVC–TdiFRC)/TdiFRC×100%. DM, the oxygenation index (the ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen), and the rapid shallow breathing index (RSBI) were measured. Results: Successful liberation from mechanical ventilation was observed in 209 patients. There were no significant differences in the TdiFRC (0.3±0.1 cm vs. 0.3±0.1 cm) or TdiFVC (0.3±0.1 cm vs. 0.2±0.1 cm) between the ventilator withdrawal success group and the ventilator withdrawal failure group (P>0.05). The TF was greater in the ventilator withdrawal success group than in the ventilator withdrawal failure group (40.8%±15.8% vs. 37.7%±9.2%, P<0.01). DM in the ventilator withdrawal success group was greater than that in the ventilator withdrawal failure group (1.5±0.5 cm vs. 1.2±0.4 cm, P=0.040). The RSBI was lower in the ventilator withdrawal success group than in the ventilator withdrawal failure group (74.3±25.6 breaths·min–1·L –1 vs. 89.9±34.5 breaths·min–1·L –1, P<0.01). Conclusions: Diaphragmatic ultrasound can be used to predict the success of ventilator withdrawal in patients with ARDS.

Cardiology
Diagnostic accuracy of left ventricular outflow tract velocity time integral versus inferior vena cava collapsibility index in predicting post-induction hypotension during general anesthesia: an observational study: Vibhuti Sharma, Arti Sharma, Arvind Sethi, Jyoti Pathania; Acute Crit Care. 2024;39(1):117-126. Published online February 23, 2024; DOI: https://doi.org/10.4266/acc.2023.00913

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Abstract PDF

Background
Point of care ultrasound (POCUS) is being explored for dynamic measurements like inferior vena cava collapsibility index (IVC-CI) and left ventricular outflow tract velocity time integral (LVOT-VTI) to guide anesthesiologists in predicting fluid responsiveness in the preoperative period and in treating post-induction hypotension (PIH) with varying accuracy.
Methods
In this prospective, observational study on included 100 adult patients undergoing elective surgery under general anesthesia, the LVOT-VTI and IVC-CI measurements were performed in the preoperative room 15 minutes prior to surgery, and PIH was measured for 20 minutes in the post-induction period.
Results
The incidence of PIH was 24%. The area under the curve, sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of the two techniques at 95% confidence interval was 0.613, 30.4%, 93.3%, 58.3%, 81.4%, 73.6% for IVC-CI and 0.853, 83.3%, 80.3%, 57.1%, 93.8%, 77.4% for LVOT-VTI, respectively. In multivariate analysis, the cutoff value for IVC-CI was >51.5 and for LVOT-VTI it was ≤17.45 for predicting PIH with odd ratio [OR] of 8.491 (P=0.025) for IVCCI and OR of 17.427 (P<0.001) for LVOT. LVOT-VTI assessment was possible in all the patients, while 10% of patients were having poor window for IVC measurements.
Conclusions
We recommend the use of POCUS using LVOT-VTI or IVC-CI to predict PIH, to decrease the morbidity of patients undergoing surgery. Out of these, we recommend LVOT-VTI measurements as it has showed a better diagnostic accuracy (77.4%) with no failure rate.

Citations

Citations to this article as recorded by

Left Ventricular Outflow Indices in Chronic Systolic Heart Failure: Thresholds and Prognostic Value
Frank L. Dini, Valentina Barletta, Piercarlo Ballo, Giovanni Cioffi, Nicola Riccardo Pugliese, Andrea Rossi, Gani Bajraktari, Stefano Ghio, Michael Y. Henein
Echocardiography.2025;[Epub] CrossRef
Perioperative Focused Transthoracic Echocardiogram Evaluations for Elderly Hip Fractures: A Narrative Review of Literature and Recommendations
Michael Armaneous, John Bouz, Tiffany Ding, Christopher Baker, Alina Kim, Avoumia Mourkus, Charles Schoepflin, Justin Calvert
A&A Practice.2025; 19(3): e01944. CrossRef
The Relationship Between Age and the Propofol Dose for Anesthesia Induction: A Single-Center Retrospective Study Utilizing Neural Network Model Simulation
Kazuki Nishimura, Kenji Hirata, Fujita Noriaki, Akira Watabe, Yuji Morimoto
Applied Sciences.2025; 15(11): 6052. CrossRef
Perioperative point-of-care ultrasound
Brett J Wakefield, Nakul Kumar, Andrew Shaw
Journal of Translational Critical Care Medicine.2025;[Epub] CrossRef
Preoperative patient risk factors for intraoperative hypotension: a systematic review and meta-analysis
Nils Daum, Daniel Bill, Moritz Thiele, Julian Felber, Dario von Wedel, Claudia Spies, Felix Balzer, Rudolf Mörgeli, Oliver Hunsicker, Anika Müller, Dennis Contag, Anne Pohrt, Annika Bald, Max Kayser, Sascha Treskatsch, Maximilian Markus
Frontiers in Cardiovascular Medicine.2025;[Epub] CrossRef
The Use of the Perfusion Index to Predict Post-Induction Hypotension in Patients Undergoing General Anesthesia: A Systematic Review and Meta-Analysis
Kuo-Chuan Hung, Shu-Wei Liao, Chia-Li Kao, Yen-Ta Huang, Jheng-Yan Wu, Yao-Tsung Lin, Chien-Ming Lin, Chien-Hung Lin, I-Wen Chen
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Mary Rose Gaylor, David N. Hager, Kathleen Tyson
Critical Care Clinics.2024; 40(3): 523. CrossRef

Pulmonary
The Use of Lung Ultrasound in a Surgical Intensive Care Unit: Hyung Koo Kang, Hyo Jin So, Deok Hee Kim, Hyeon-Kyoung Koo, Hye Kyeong Park, Sung-Soon Lee, Hoon Jung; Korean J Crit Care Med. 2017;32(4):323-332. Published online November 30, 2017; DOI: https://doi.org/10.4266/kjccm.2017.00318

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Abstract PDF

Background
Pulmonary complications including pneumonia and pulmonary edema frequently develop in critically ill surgical patients. Lung ultrasound (LUS) is increasingly used as a powerful diagnostic tool for pulmonary complications. The purpose of this study was to report how LUS is used in a surgical intensive care unit (ICU).
Methods
This study retrospectively reviewed the medical records of 67 patients who underwent LUS in surgical ICU between May 2016 and December 2016.
Results
The indication for LUS included hypoxemia (n = 44, 65.7%), abnormal chest radiographs without hypoxemia (n = 17, 25.4%), fever without both hypoxemia and abnormal chest radiographs (n = 4, 6.0%), and difficult weaning (n = 2, 3.0%). Among 67 patients, 55 patients were diagnosed with pulmonary edema (n = 27, 41.8%), pneumonia (n = 20, 29.9%), diffuse interstitial pattern with anterior consolidation (n = 6, 10.9%), pneumothorax with effusion (n = 1, 1.5%), and diaphragm dysfunction (n = 1, 1.5%), respectively, via LUS. LUS results did not indicate lung complications for 12 patients. Based on the location of space opacification on the chest radiographs, among 45 patients with bilateral abnormality and normal findings, three (6.7%) and two (4.4%) patients were finally diagnosed with pneumonia and atelectasis, respectively. Furthermore, among 34 patients with unilateral abnormality and normal findings, two patients (5.9%) were finally diagnosed with pulmonary edema. There were 27 patients who were initially diagnosed with pulmonary edema via LUS. This diagnosis was later confirmed by other tests. There were 20 patients who were initially diagnosed with pneumonia via LUS. Among them, 16 and 4 patients were finally diagnosed with pneumonia and atelectasis, respectively.
Conclusions
LUS is useful to detect pulmonary complications including pulmonary edema and pneumonia in surgically ill patients.

Citations

Citations to this article as recorded by

Lung Ultrasound in the Critically Ill
Jin Sun Cho
The Korean Journal of Critical Care Medicine.2017; 32(4): 356. CrossRef

Neurology
The Effect of Electrical Muscle Stimulation and In-bed Cycling on Muscle Strength and Mass of Mechanically Ventilated Patients: A Pilot Study: Kyeongyoon Woo, Jeongmin Kim, Hye Bin Kim, Hyunwoo, Choi, Kibum Kim, Donghyung Lee, Sungwon Na; Acute Crit Care. 2018;33(1):16-22. Published online February 14, 2017; DOI: https://doi.org/10.4266/acc.2017.00542

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Abstract PDF

Background
Critically ill patients experience muscle weakness, which leads to functional disability. Both functional electrical stimulation (FES) and in-bed cycling can be an alternative measure for intensive care unit (ICU) patients who are not feasible for active exercise. The aim of this study was to examine whether FES and in-bed cycling have a positive effect on muscle mass in ICU patients.
Methods
Critically ill patients who received mechanical ventilation for at least 24 hours were included. After passive range of motion exercise, in-bed cycling was applied for 20 minutes, and FES was applied for 20 minutes on the left leg. The right leg received in-bed cycling and the left leg received both FES and in-bed cycling. Thigh circumferences and rectus femoris cross-sectional area (CSA) were assessed with ultrasonography before and after the intervention. Muscle strength was assessed by Medical Research Council scale.
Results
A total of 10 patients were enrolled in this study as a pilot study. Before and after the intervention, the CSA of right rectus femoris increased from 5.08 ± 1.51 cm² to 6.01 ± 2.21 cm² , which was statistically significant (P = 0.003). The thigh circumference was also increased and statistically significant (P = 0.006). There was no difference between left and right in regard to FES application. There is no significant change in muscle strength before and after the intervention (right and left, P = 0.317 and P = 0.368, respectively).
Conclusions
In-bed cycling increased thigh circumferences rectus femoris CSA. Adding FES did not show differences.

Citations

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Assisted mobilisation in critical patients with COVID-19
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Methodologies and clinical applications of lower limb muscle ultrasound in critically ill patients: a systematic review and meta-analysis
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Evaluating Muscle Mass Changes in Critically Ill Patients: Rehabilitation Outcomes Measured by Ultrasound and Bioelectrical Impedance
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Asmaa Badr Eldin Opoda, Sohair Moustafa Soliman, Mona Blough El Mourad Fayad, Taysser Mahmoud Abdulrahim
Bali Journal of Anesthesiology.2024; 8(4): 215. CrossRef
Human skeletal muscle size with ultrasound imaging: a comprehensive review
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Cardiology
The Effect of the Valsalva Maneuver on the External Jugular Vein: Ho Sik Moon, Sung Hoon Jung, Sie Hyeon Yoo, Jae Young Ji, Hae Jin Lee; Korean J Crit Care Med. 2015;30(3):158-163. Published online August 31, 2015; DOI: https://doi.org/10.4266/kjccm.2015.30.3.158

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Abstract PDF: Background
The external jugular vein (EJV) is a useful intravenous (IV) cannulation site for anesthesiologists, although it has a relatively high failure rate. Unlike other central veins, visualization of the EJV is important during IV cannulation, and the Valsalva maneuver distends the jugular venous system. However, the relationship between the maneuver and EJV visibility remains unknown. This study compared EJV visibility before and after the Valsalva maneuver.
Methods
This was a prospective observational study that included 200 participants. After the induction of anesthesia, EJV visibility grade, depth from the skin to the EJV superficial surface (EJV depth), and EJV cross-sectional area (CSA) before the Valsalva maneuver were measured. The same parameters were measured after the Valsalva maneuver was performed. The EJV visibility grade was defined as grade A: good appearance and good palpation, grade B: poor appearance and good palpation, and grade C: poor appearance and poor palpation.
Results
Patient body mass index and EJV depth affected the EJV visibility grade before the Valsalva maneuver (p < 0.05), although EJV CSA did not. The Valsalva maneuver distended EJV CSA and reduced EJV depth, although these changes were not correlated with EJV visibility grade. With regard to EJV visibility, 34.0% of grade B cases and 20.0% of grade C cases were improved by the Valsalva maneuver.
Conclusions
Although the Valsalva maneuver improved EJV CSA and EJV depth, it did not greatly affect EJV visibility grade.

Pulmonary
The Usefulness of Intensivist-Performed Bedside Drainage of Pleural Effusion via Ultrasound-Guided Pigtail Catheter: Joo Won Min, Joon Young Ohm, Byung Seok Shin, Jun Wan Lee, Sang Il Park, Seok Hwa Yoon, Yong Sup Shin, Dong Il Park, Chaeuk Chung, Jae Young Moon; Korean J Crit Care Med. 2014;29(3):177-182. Published online August 31, 2014; DOI: https://doi.org/10.4266/kjccm.2014.29.3.177

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Abstract PDF: BACKGROUND
There has been little data reporting the usefulness of intensivist-performed bedside drainage of pleural effusion via ultrasound (US)-guided pigtail catheter. The objective of this study is to clarify the usefulness and safety of these methods in comparison with radiologist-performed procedures.
METHODS
Data of patients with pleural effusion treated with US-guided pigtail catheter drainage were analyzed. All procedures were performed from September 2012 to September. 2013 by a well-trained intensivist or radiologist.
RESULTS
Pleural effusion was drained in 25 patients in 33 sessions. A radiologist performed 21 sessions, and an intensivist performed 12 sessions. Procedures during mechanical ventilation were performed in 15 (71.4%) patients by a radiologist and in 10 (83.3%) by an intensivist (p = 0.678). The success rate was not significantly different in radiologist- and intensivist-performed procedures, 95.2% (20/21) and 83.3% (10/12), respectively (p = 0.538). The average duration for procedures (including in-hospital transfer) was longer in radiologist-performed cases (p = 0.001). Although the results are limited because of the small population size, aggravation of oxygenation, CO2 retention, and decrease of mean arterial blood pressure were not statistically different in the groups. Pigtail-associated complications including hemothorax, pneumothorax, hepatic perforation, empyema, kink in the catheter, and subcutaneous hematoma were not found.
CONCLUSIONS
Intensivist-performed bedside drainage of pleural effusion via ultrasound (US)-guided pigtail catheter is useful and safe and may be recommended in some patients in an intensive care unit.

Case Report

Ultrasound Guided Bronchoscopic Balloon Dilatation in the Management of Tracheal Stenosis: A Case Report: Jung Min Hong, Tae Kyun Kim, Ah Reum Cho, Do Won Lee, Yun Hee Han, Jae Young Kwon; Korean J Crit Care Med. 2012;27(2):139-142.; DOI: https://doi.org/10.4266/kjccm.2012.27.2.139

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Abstract PDF: We performed a balloon dilatation without a fluoroscopy monitoring by ultrasound. A 44 year old female patient was presented with subglottic stenosis, due to prolonged intubation. Although she had undergone tracheal resection and end-to-end anastomosis, the tracheal stenosis had recurred. She was scheduled for balloon dilatation. However, fluoroscopic guidance was not available, and thus, we used ultrasonographic monitoring as an alternative method. We performed a transverse scan, just cranial to the suprasternal notch, and we obtained a real time image of the trachea dilated by the balloon. We suggest that ultrasonographic monitoring is a useful adjunct to balloon dilatation in patients with tracheal stenosis.

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