Showing papers in "Current Opinion in Critical Care in 2019"
TL;DR: Identification of distinct subgroups or phenotypes in ARDS may impact future conduct of clinical trials and can enhance the understanding of the disorder, with potential future clinical implications.
Abstract: Purpose of review To provide an overview of the current research in identifying homogeneous subgroups and phenotypes in ARDS. Recent findings In recent years, investigations have used either physiology, clinical data, biomarkers or a combination of these to stratify patients with ARDS into distinct subgroups with divergent clinical outcomes. In some studies, there has also been evidence of differential treatment response within subgroups. Physiologic approaches include stratification based on P/F ratio and ventilatory parameters; stratification based on P/F ratio is already being employed in clinical trials. Clinical approaches include stratification based on ARDS risk factor or direct vs. indirect ARDS. Combined clinical and biological data has been used to identify two phenotypes across five cohorts of ARDS, termed hyperinflammatory and hypoinflammatory. These phenotypes have widely divergent clinical outcomes and differential response to mechanical ventilation, fluid therapy, and simvastatin in secondary analysis of completed trials. Next steps in the field include prospective validation of inflammatory phenotypes and integration of high-dimensional 'omics' data into our understanding of ARDS heterogeneity. Summary Identification of distinct subgroups or phenotypes in ARDS may impact future conduct of clinical trials and can enhance our understanding of the disorder, with potential future clinical implications.
114 citations
TL;DR: Drugs lead to AKI through mechanisms that involve their inherent toxicity as well as their transport and handling by the kidneys, as seen with immune checkpoint inhibitors.
Abstract: Purpose of reviewMedications are a relatively common cause of acute kidney injury (AKI), especially in hospitalized patients who are exposed to numerous agents. Drug-related acute tubular/tubulointerstitial injury is the most common cause of AKI associated with these agents. Toxic effects of drugs a
101 citations
TL;DR: The role of spontaneous breathing during mechanical ventilation in ARDS is updated and summarized, which can be beneficial or deleterious, depending on the strength of spontaneous activity and severity of lung injury.
Abstract: Purpose of review Facilitating spontaneous breathing has been traditionally recommended during mechanical ventilation in acute respiratory distress syndrome (ARDS). However, early, short-term use of neuromuscular blockade appears to improve survival, and spontaneous effort has been shown to potentiate lung injury in animal and clinical studies. The purpose of this review is to describe the beneficial and deleterious effects of spontaneous breathing in ARDS, explain potential mechanisms for harm, and provide contemporary suggestions for clinical management. Recent findings Gentle spontaneous effort can improve lung function and prevent diaphragm atrophy. However, accumulating evidence indicates that spontaneous effort may cause or worsen lung and diaphragm injury, especially if the ARDS is severe or spontaneous effort is vigorous. Recently, such effort-dependent lung injury has been termed patient self-inflicted lung injury (P-SILI). Finally, several approaches to minimize P-SILI while maintaining some diaphragm activity (e.g. partial neuromuscular blockade, high PEEP) appear promising. Summary We update and summarize the role of spontaneous breathing during mechanical ventilation in ARDS, which can be beneficial or deleterious, depending on the strength of spontaneous activity and severity of lung injury. Future studies are needed to determine ventilator strategies that minimize injury but maintaining some diaphragm activity.
57 citations
TL;DR: Liver support systems such as MARS and TPE may temporarily improve systemic haemodynamics and the degree of encephalopathy, however, TPE is the only procedure that improves survival in patients with ALF.
Abstract: Purpose of reviewLiver failure is a life-threatening condition, and an artificial liver is highly desirable to replace the failing liver-functions in the waiting time for liver regeneration to happen or until liver transplantation can be undertaken. This review focuses on the efficacy of using artif
54 citations
TL;DR: The current use of vasopressor and inotrope agents during cardiogenic shock is reviewed and their use should be limited as a temporary bridge to recovery, mechanical circulatory support or heart transplantation.
Abstract: Purpose of reviewData and interventional trials regarding vasopressor and inotrope use during cardiogenic shock are scarce. Their use is limited by their side-effects and the lack of solid evidence regarding their effectiveness in improving outcomes. In this article, we review the current use of vas
44 citations
TL;DR: A novel diaphragm-protective ventilation strategy, avoiding the harmful effects of both excessive and insufficient inspiratory effort, has the potential to substantially improve outcomes for patients.
Abstract: Purpose of review Diaphragm dysfunction is common in mechanically ventilated patients and predisposes them to prolonged ventilator dependence and poor clinical outcomes. Mechanical ventilation is a major cause of diaphragm dysfunction in these patients, raising the possibility that diaphragm dysfunction might be prevented if mechanical ventilation can be optimized to avoid diaphragm injury - a concept referred to as diaphragm-protective ventilation. This review surveys the evidence supporting the concept of diaphragm-protective ventilation and introduces potential routes and challenges to pursuing this strategy. Recent findings Mechanical ventilation can cause diaphragm injury (myotrauma) by a variety of mechanisms. An understanding of these various mechanisms raises the possibility of a new approach to ventilatory management, a diaphragm-protective ventilation strategy. Deranged inspiratory effort is the main mediator of diaphragmatic myotrauma; titrating ventilation to maintain an optimal level of inspiratory effort may help to limit diaphragm dysfunction and accelerate liberation of mechanical ventilation. Summary Mechanical ventilation can cause diaphragm injury and weakness. A novel diaphragm-protective ventilation strategy, avoiding the harmful effects of both excessive and insufficient inspiratory effort, has the potential to substantially improve outcomes for patients.
43 citations
TL;DR: Frailty is a valuable risk stratification tool that better captures the state of augmented vulnerability of older adults and may guide targeted interventions, such as prehabilitation, to optimize geriatric patients undergoing surgery.
Abstract: Purpose of reviewThe aging surgical population constitutes a unique challenge to clinicians across the spectrum of care. Frailty is a valuable tool for preoperative risk stratification and may guide targeted interventions, such as prehabilitation. The aim of this review is to revise the recent liter
39 citations
TL;DR: The management of patients with acute respiratory failure in LMICs should focus on avoiding intubation where possible, improving the safety of mechanical ventilation and expediting weaning, and the development and trialing of robust and context-appropriate respiratory support technology.
Abstract: Purpose of review This review focuses on the emerging body of literature regarding the management of acute respiratory failure in low- and middle-income countries (LMICs). The aim is to abstract management principles that are of relevance across a variety of settings where resources are severely limited. Recent findings Mechanical ventilation is an expensive intervention associated with considerable mortality and a high rate of iatrogenic complications in many LMICs. Recent case series report crude mortality rates for ventilated patients of between 36 and 72%. Measures to avert the need for invasive mechanical ventilation in LMICs are showing promise: bubble continuous positive airway pressure has been demonstrated to decrease mortality in children with acute respiratory failure and trials suggest that noninvasive ventilation can be conducted safely in settings where resources are low. Summary The management of patients with acute respiratory failure in LMICs should focus on avoiding intubation where possible, improving the safety of mechanical ventilation and expediting weaning. Future directions should involve the development and trialing of robust and context-appropriate respiratory support technology.
38 citations
TL;DR: TCS have become the cornerstone of the management of patients with cardiogenic shock, although the evidence supporting their efficacy is limited and VA-ECMO is considered the first-line option, with a growing number of accepted and emerging indications.
Abstract: Purpose of reviewTemporary circulatory support (TCS) with venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used as a salvage therapy for patients with refractory cardiogenic shock. This article provides an overview of VA-ECMO principles, indications, management, complicatio
38 citations
TL;DR: A narrative review on the recent developments in enriching patient populations for future sepsis and ARDS trials shows how a biomarker that is altered by the intervention, such as lymphocyte count for recombinant interleukin-7 therapy and higher check point inhibitor expression for anti-check point treatments in sepsi could identify a higher treatment effect population for future trials.
Abstract: PURPOSE OF REVIEW Sepsis and acute respiratory distress syndrome (ARDS) are two heterogenous acute illnesses where numerous RCTs have indeterminate results. We present a narrative review on the recent developments in enriching patient populations for future sepsis and ARDS trials. RECENT FINDINGS Many researchers are actively pursuing enrichment strategies to reduce heterogeneity to increase the sensitivity of future trials. Enrichment refers to the use of measurable patient characteristics, known before randomisation, to refine trial populations. Biomarkers could increase the diagnostic certainty of sepsis, whereas chest radiology training to enhance reliability of interpretation and stabilisation period of mechanical ventilation have been considered to increase the diagnostic certainty of ARDS. Clinical and biomarker data analyses identifies four to six sepsis clinical phenotypes and two ARDS clinical phenotypes. Similarly, leukocyte gene expression data identifies two to four sepsis molecular phenotypes. Use of a test-dose identifies ARDS subpopulations who are likely to benefit from higher PEEP. Early-phase trials report how a biomarker that is altered by the intervention, such as lymphocyte count for recombinant interleukin-7 therapy and higher check point inhibitor expression for anti-check point treatments in sepsis, could identify a higher treatment effect population for future trials. SUMMARY Enrichment reduces heterogeneity and will enhance the sensitivity of future trials. However, enrichment, even when it identifies more homogenous populations, may not be efficient to deploy in trials or clinical practice.
37 citations
TL;DR: This review discusses the various monitoring modalities relevant to the management of patients on venovenous ECMO (VV ECMO) and venoarterial (VA ECMO), and emphasizes how differences between VV and VA ECMO are reflected in distinct approaches to monitoring.
Abstract: Purpose of reviewHemodynamic monitoring in ECMO patients requires familiarity with the underlying pathophysiology and circulatory mechanics of extracorporeal flow. This review discusses the various monitoring modalities relevant to the management of patients on venovenous ECMO (VV ECMO) and venoarte
TL;DR: Current knowledge on pathogenesis and clinical manifestations of severe influenza, focusing on outcome and complications in critically ill patients, is summarized.
Abstract: Purpose of reviewOverview of influenza infection, focusing on outcome and complications in critically ill patients. We also discuss relevant elements in immunopathogenesis and their role as predictors of severity.Recent findingsPandemic influenza A (H1N1) virus circulates seasonally and remains the
TL;DR: OHCA survivors should be routinely screened for cognitive and emotional problems, and when patients with mild cognitive deficits participate in cardiac rehabilitation, their program should be adjusted to their cognitive abilities.
Abstract: Purpose of review Most survivors of out-of-hospital cardiac arrest (OHCA) suffer from cardiologic symptoms and approximately half of them experience cognitive problems because of hypoxic brain damage. Symptoms of anxiety and depression are also common. This review aims to give an overview of recent literature on rehabilitation treatment aiming at improvement of quality of life after OHCA. Recent findings Existing cognitive screening tools are now validated for OHCA survivors. OHCA patients with cognitive deficits may have lower exercise capacity. Cardiac rehabilitation seems to be well tolerated for OHCA survivors, with outcomes comparable to myocardial infarction patients. Many caregivers suffer from posttraumatic stress disorder and emotional stress. Interventions for them are available. Implementation of integrated programs covering both cognitive and cardiac rehabilitation is hampered by lack of knowledge and organizational barriers. Summary OHCA survivors should be routinely screened for cognitive and emotional problems. When patients with mild cognitive deficits participate in cardiac rehabilitation, their program should be adjusted to their cognitive abilities. For patients with severe cognitive or emotional problems, individualized rehabilitation seems favorable. Integrated rehabilitation treatment between cardiac and cognitive rehabilitation departments is recommended. Attention should be paid to the burden of caregivers.
TL;DR: The present article reviews the clinical conditions of ACS and IAH and the latest updates from pathophysiology to the new management flowchart resulting from the implantation of point-of-care ultrasound in the monitoring and assistance of medical treatment of IAH/ACS.
Abstract: Purpose of reviewAbdominal compartment syndrome (ACS) is a severe complication resulting from an acute and sustained increase in intra-abdominal pressure (IAP), causing significant morbidity and mortality. Although prospective double-blinded, randomized trials, and evidence-based analysis are lackin
TL;DR: The approach to diagnose invasive pulmonary aspergillosis in the absence of lung biopsy in ICU patients is reviewed, based on four pillars: mycology, medical imaging, underlying conditions, and acute disease expression.
Abstract: Purpose of reviewThe approach to diagnose invasive pulmonary aspergillosis in the absence of lung biopsy in ICU patients is reviewed. This approach should be based on four pillars: mycology, medical imaging, underlying conditions, and acute disease expression.Recent findingsDiagnosing invasive pulmo
TL;DR: Challenges of long-term follow-up require careful consideration by study investigators to ensure their collective success in data integration and a better understanding of underlying mechanisms of mortality and morbidity seen in critical care survivorship.
Abstract: Purpose of review Evaluating longer term mortality, morbidity, and quality of life in survivors of critical illness is a research priority. This review details the challenges of long-term follow-up studies of critically ill patients and highlights recently proposed methodological solutions. Recent findings Barriers to long-term follow-up studies of critical care survivors include high rates of study attrition because of death or loss to follow-up, data missingness from experienced morbidity, and lack of standardized outcome as well as reporting of key covariates. A number of recent methods have been proposed to reduce study patients attrition, including minimum data set selection and visits to transitional care or home settings, yet these have significant downsides as well. Conducting long-term follow-up even in the absence of such models carries a high expense, as personnel are very costly, and patients/families require reimbursement for their time and inconvenience. Summary There is a reason why many research groups do not conduct long-term outcomes in critical care: it is very difficult. Challenges of long-term follow-up require careful consideration by study investigators to ensure our collective success in data integration and a better understanding of underlying mechanisms of mortality and morbidity seen in critical care survivorship.
TL;DR: A 'personalized' approach to glycemic control in the critically ill, with recognition of preadmission glycemia, is supported by an emerging literature and is suitable for testing in future interventional trials.
Abstract: Purpose of review To summarize the advances in literature that support the best current practices regarding glucose control in the critically ill. Recent findings There are differences between patients with and without diabetes regarding the relationship of glucose metrics during acute illness to mortality. Among patients with diabetes, an assessment of preadmission glycemia, using measurement of Hemoglobin A1c (HgbA1c) informs the choice of glucose targets. For patients without diabetes and for patients with low HgbA1c levels, increasing mean glycemia during critical illness is independently associated with increasing risk of mortality. For patients with poor preadmission glucose control the appropriate blood glucose target has not yet been established. New metrics, including stress hyperglycemia ratio and glycemic gap, have been developed to describe the relationship between acute and chronic glycemia. Summary A 'personalized' approach to glycemic control in the critically ill, with recognition of preadmission glycemia, is supported by an emerging literature and is suitable for testing in future interventional trials.
TL;DR: Recent advances in the understanding of ventilatory physiology during CPR shows that capnogram analysis not only provides information on the quality of resuscitation but also on the amount of ventilation produced by chest compressions and on the total amount of vents.
Abstract: Purpose of reviewIn the setting of cardiopulmonary resuscitation (CPR), classical physiological concept about ventilation become challenging. Ventilation may exert detrimental hemodynamic effects that must be balanced with its expected benefits. The risks of hyperventilation have been thoroughly add
TL;DR: The relationship between nutrition and the gut microbiome in critical illness is described and nutrition and supplements appear to play a significant role in modulating the microbiome in health, yet the relationship incritical illness is unclear.
Abstract: Purpose of review The present review aims to describe the relationship between nutrition and the gut microbiome in critical illness. Recent findings Critical illness disrupts not only cells of human origin but also the intestinal microbiome, with a decrease in bacterial diversity and transformation into a pathobiome. Under basal conditions, nutrition profoundly alters microbial composition with significant salutatory effects on human health. In critical illness, enteral nutrition is recommended and has theoretical (but not proven) advantages towards improved inner microbial health and diminution of bacterial translocation. Dietary supplements such as probiotics and fiber have been shown to improve microbial derangements in health. However, their impact on the microbiome in critical illness is unclear and although they may have some beneficial effects on patient-centric outcomes, they do not alter mortality. The precise mechanisms of how nutrition and dietary supplements modulate the gut microbiome remain to be determined. Summary Nutrition and supplements such as probiotics appear to play a significant role in modulating the microbiome in health, yet the relationship in critical illness is unclear. Further investigation is required to determine the mechanistic determinants of the impact of nutrition on the microbiome in critical illness and the potential clinical implications of this.
TL;DR: This review provides an update on the risk factors, causes, and treatment approaches to HSCT-associated AKI, especially the role of the complement system in its pathophysiology.
Abstract: Purpose of reviewAcute kidney injury (AKI) in the setting of hematopoietic stem cell transplantation (HSCT) is common in pediatric and adult patients. The incidence ranges from 12 to 66%, and development of AKI in the posttransplant course is independently associated with higher mortality.Recent fin
TL;DR: Although energy expenditure can now be measured, the authors miss indicators of early endogenous energy production and of protein needs, so a pragmatic ramping up of extrinsic energy provision by nutrition support reduces the risk of overfeeding-related adverse effects.
Abstract: PURPOSE OF REVIEW Any critical care therapy requires individual adaptation, despite standardization of the concepts supporting them. Among these therapies, nutrition care has been repeatedly shown to influence clinical outcome. Individualized feeding is the next needed step towards optimal global critical care. RECENT FINDINGS Both underfeeding and overfeeding generate complications and should be prevented. The long forgotten endogenous energy production, maximal during the first 3 to 4 days, should be integrated in the nutrition plan, through a slow progression of feeding, as full feeding may result in early overfeeding. Accurate and repeated indirect calorimetry is becoming possible thanks to the recent development of a reliable, easy to use and affordable indirect calorimeter. The optimal timing of the prescription of the measured energy expenditure values as goal remains to be determined. Optimal protein prescription remains difficult as no clinically available tool has yet been identified reflecting the body needs. SUMMARY Although energy expenditure can now be measured, we miss indicators of early endogenous energy production and of protein needs. A pragmatic ramping up of extrinsic energy provision by nutrition support reduces the risk of overfeeding-related adverse effects.
TL;DR: Novel, noninvasive methods to quantify microvascular perfusion have the potential to guide treatment in terms of optimizing organ perfusion and oxygenation probably paving the way for an individualized therapy.
Abstract: Purpose of reviewAdequate tissue perfusion is of utmost importance to avoid organ failure in patients with cardiogenic shock. Within the recent years, the microcirculation, defined as the perfusion of the smallest vessels, has been identified to play a crucial role. Microcirculatory changes may incl
TL;DR: While immune-allergic reaction to numerous drugs is the most common cause of AIN, other underlying systemic diseases may also be involved, and therefore, every patient should undergo a complete diagnostic evaluation.
Abstract: Purpose of reviewThe purpose of this review is to describe the most common causes of acute interstitial nephritis (AIN), the diagnostic work-up and the therapeutic management.Recent findingsSeveral case series and registries have found an increasing incidence of AIN, especially among older patients.
TL;DR: It is believed that the approach to fluid therapy must be individualized based on the cause of shock as well as the patient's major diagnosis, comorbidities and hemodynamic and respiratory status, and a conservative, physiologically guided Approach to fluid resuscitation likely improves patient outcomes.
Abstract: Purpose of reviewShock, best defined as acute circulatory failure is classified into four major groups, namely hypovolemic, cardiogenic, obstructive, and distributive (vasodilatory). The purpose of this review is to provide a practical approach to fluid optimization in patients with the four types o
TL;DR: An overview of AKI definitions is provided, challenges in quantifying renal impairment in cirrhosis are highlighted, novel biomarkers may assist in identification of acute tubular necrosis and persistent/severe AKI are listed, and transplantation implications are summarized.
Abstract: Purpose of reviewAcute kidney injury (AKI) in cirrhosis consists of varying phenotypes, with hepatorenal syndrome (HRS) representing a single entity. Prompt recognition and diagnosis of AKI cause identifies appropriate therapeutic measures. This review provides an overview of AKI definitions, highli
TL;DR: The role of microcopic techniques is still hampered by the lack of clearly defined targets as well as interventions specifically targeting the microcirculation, and clinical and biological surrogates of microcirculatory assessment can be used at bedside.
Abstract: Purpose of review The present review discusses the current role of microcirculatory assessment in the hemodynamic monitoring of critically ill patients. Recent findings Videomicroscopic techniques have demonstrated that microvascular perfusion is altered in critically ill patients, and especially in sepsis. These alterations are associated with organ dysfunction and poor outcome. Handheld microscopes can easily be applied on the sublingual area of critically ill patients. Among the specific limitations of these techniques, the most important is that these can mostly investigate the sublingual microcirculation. The representativity of the sublingual area may be questioned, especially as some areas may sometimes be more affected than the sublingual area. Also, evaluation of the sublingual area may be difficult in nonintubated hypoxemic patients. Alternative techniques include vasoreactivity tests using either transient occlusion or performing a thermal challenge. These techniques evaluate the maximal dilatory properties of the microcirculation but do not really evaluate the actual microvascular perfusion. Focusing on the glycocalyx may be another option, especially with biomarkers of glycocalyx degradation and shedding. Evaluation of the glycocalyx is still largely experimental, with different tools still in investigation and lack of therapeutic target. Venoarterial differences in PCO2 are inversely related with microvascular perfusion, and can thus be used as surrogate for microcirculation assessment. Several limitations prevent the regular use in clinical practice. The first is the difficult use of some of these techniques outside research teams, whereas nurse-driven measurements are probably desired. The second important limitation for daily practice use is the lack of uniformly defined endpoint. The final limitation is that therapeutic interventions affecting the microcirculation are not straightforward. Summary Clinical and biological surrogates of microcirculatory assessment can be used at bedside. The role of microvideoscopic techniques is still hampered by the lack of clearly defined targets as well as interventions specifically targeting the microcirculation.
TL;DR: ICU management of ALF has improved such that liver transplantation is not required in some cases, and high-volume plasma exchange (HVP) has emerged as a potential therapy for patients who may not be good Liver transplantation candidates.
Abstract: Purpose of reviewThis review describes the current intensive care management of acute liver failure (ALF) and the latest evidence for emerging therapies.Recent findingsMortality from ALF continues to improve and in some cases, medical therapy can negate the need for liver transplantation because of
TL;DR: This review focuses on the renal effects of PFCs, with the attempt to clarify their occurrence and pathogenetic mechanisms, and further studies are required on the potential synergic negative effect of P FCs co-exposure with other pollutants.
Abstract: Purpose of review There is increasing interest in the environmental and human damage caused by pollutants. Big efforts are continuously made to monitor their levels and identify safe thresholds. For this purpose, an essential step is to prioritize harmful substances and understand their effect on human body. Perfluorinated compounds (PFCs) deserve particular attention because of their wide diffusion and potential correlation with different diseases including glucose intolerance, hyperlipidaemia, thyroid diseases, gestational diabetes mellitus and hypertension, testicular and genitourinary cancer as well as impaired kidney function. This review focuses on the renal effects of PFCs, with the attempt to clarify their occurrence and pathogenetic mechanisms. Recent findings We reviewed MEDLINE and EMBASE citations between 31 October 2017 and 31 May 2019 and selected human studies measuring PFCs exposure, kidney function markers and the ability of haemodialysis to remove PFCs from the circulating blood. It has been currently clarified that exposure to PFCs is linked with an impaired kidney function and that they can be removed by blood purification. Summary Further studies are required on the potential synergic negative effect of PFCs co-exposure with other pollutants as well as animal studies about the removal capacity of different haemodialysis membranes.
TL;DR: Treatment of any significant coagulopathy should not be based solely on standard laboratory tests, and thrombosis prophylaxis has to be considered in susceptible populations.
Abstract: Purpose of reviewThis review provides insight into our current understanding of the pathophysiology and treatment of coagulopathy associated with liver failure, and bleeding risk assessment.Recent findingsPatients with end-stage liver disease (ESLD) have a rebalanced coagulation profile and are at r
TL;DR: In this article, the authors discuss recent updates in fluid management and use of hyperosmolar therapy in neurocritical care, and suggest that maintaining euvolemia with crystalloids seems to be the recommended fluid resuscitation for neuro-critical care patients.
Abstract: Purpose of reviewTo discuss recent updates in fluid management and use of hyperosmolar therapy in neurocritical care.Recent findingsMaintaining euvolemia with crystalloids seems to be the recommended fluid resuscitation for neurocritical care patients. Buffered crystalloids have been shown to reduce