Dealing with an uncertain or missed diagnosis is commonplace in the intensive care unit setting. Affected patients are subject to a potential decrease in quality of care and a greater risk of a poor outcome. The diagnostic process is a complex task that starts with information gathering, followed by integration and interpretation of data, hypothesis generation and, finally, confirmation of a (hopefully correct) diagnosis. This may be particularly challenging in the patient who is critically ill where a good history may not be forthcoming and/or clinical, laboratory and imaging features are non-specific. The aim of this narrative review is to analyse and describe common causes of diagnostic error in the intensive care unit, highlighting the multiple types of cognitive bias, and to suggest a diagnostic framework. To inform this review, we performed a literature search to identify relevant articles, particularly those pertinent to unclear diagnoses in patients who are critically ill. Clinicians should be cognisant as to how they formulate diagnoses and utilise debiasing strategies. Multidisciplinary teamwork and more time spent with the patient, supported by effective and efficient use of electronic healthcare records and decision support resources, is likely to improve the quality of the diagnostic process, patient care and outcomes.

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Objectives. We adopted the near-infrared spectroscopy (NIRS) technology to monitor the spinal oxygen supply through the paraspinous muscles oxygenation in agreement with the concept of “collateral network” circulation. We retrospectively investigated our database of subjects who underwent thoraco-abdominal aorta open repair assessing for the reliability of this monitoring to predict spinal cord injury. Methods. Consecutive patients who underwent elective thoraco-abdominal aorta open repair between March 2019 and September 2021. In addition to standard monitoring, patients received the monitoring of the paraspinous muscles oxygenation by NIRS. Results. In one patient a significant drop of the mean arterial pressure (49 mmHg) and the spinal-cord perfusion pressure (31 mmHg) occurred after the aortic clamping, with a contemporary lowering of the left-side oxygenation of paraspinous muscles (<40%). Both the blood pressure and the spinal cord perfusion pressure were restored within 10 minutes, but the oxygenation remained at an unsafe level (<55%) until the end of the surgery. This same patient experienced a lower-limb paralysis post-operatively. It did not happen in the other 11 cases of the sample. Conclusions. The main finding of our retrospective analysis indicates reliability of this technology to monitor the spinal cord oxygenation during open thoraco-abdominal aortic surgery and possibly predict spinal cord injury. Still, several questions need to be addressed about the suitability of this technology to the anatomic and pathophysiology of the spinal cord circulation