Díaz‐Gómez, José L.

OBJECTIVES: A number of trials related to critical care pharmacotherapy were published in 2022. We aimed to summarize the most influential publications related to the pharmacotherapeutic care of critically ill patients in 2022. DATA SOURCES: PubMed/Medical Literature Analysis and Retrieval System Online and the Clinical Pharmacy and Pharmacology Pharmacotherapy Literature Update. STUDY SELECTION: Randomized controlled trials, prospective studies, or systematic review/meta-analyses of adult critically ill patients assessing a pharmacotherapeutic intervention and reporting clinical endpoints published between January 1, 2022, and December 31, 2022, were included in this article. DATA EXTRACTION: Articles from a systematic search and the Clinical Pharmacy and Pharmacology Pharmacotherapy Literature Update were included and stratified into clinical domains based upon consistent themes. Consensus was obtained on the most influential publication within each clinical domain utilizing an a priori defined three-round modified Delphi process with the following considerations: 1) overall contribution to scientific knowledge and 2) novelty to the literature. DATA SYNTHESIS: The systematic search and Clinical Pharmacy and Pharmacology Pharmacotherapy Literature Update yielded a total of 704 articles, of which 660 were excluded. The remaining 44 articles were stratified into the following clinical domains: emergency/neurology, cardiovascular, gastroenterology/fluids/nutrition, hematology, infectious diseases/immunomodulation, and endocrine/metabolic. The final article selected from each clinical domain was summarized following a three-round modified Delphi process and included three randomized controlled trials and three systematic review/meta-analyses. Article topics summarized included dexmedetomidine versus other sedatives during mechanical ventilation, beta-blocker treatment in the critically ill, restriction of IV fluids in septic shock, venous thromboembolism prophylaxis in critically ill adults, duration of antibiotic therapy for Pseudomonas aeruginosa ventilator-associated pneumonia, and low-dose methylprednisolone treatment in severe community-acquired pneumonia. CONCLUSIONS: This concise review provides a perspective on articles published in 2022 that are relevant to the pharmacotherapeutic care of critically ill patients and their potential impact on clinical practice.

OBJECTIVES: To describe the development and initial results of an examination and certification process assessing competence in critical care echocardiography. DESIGN: A test writing committee of content experts from eight professional societies invested in critical care echocardiography was convened, with the Executive Director representing the National Board of Echocardiography. Using an examination content outline, the writing committee was assigned topics relevant to their areas of expertise. The examination items underwent extensive review, editing, and discussion in several face-to-face meetings supervised by National Board of Medical Examiners editors and psychometricians. A separate certification committee was tasked with establishing criteria required to achieve National Board of Echocardiography certification in critical care echocardiography through detailed review of required supporting material submitted by candidates seeking to fulfill these criteria. SETTING: The writing committee met twice a year in person at the National Board of Medical Examiner office in Philadelphia, PA. SUBJECTS: Physicians enrolled in the examination of Special Competence in Critical Care Electrocardiography (CCEeXAM). MEASUREMENTS AND MAIN RESULTS: A total of 524 physicians sat for the examination, and 426 (81.3%) achieved a passing score. Of the examinees, 41% were anesthesiology trained, 33.2% had pulmonary/critical care background, and the majority had graduated training within the 10 years (91.6%). Most candidates work full-time at an academic hospital (46.9%). CONCLUSIONS: The CCEeXAM is designed to assess a knowledge base that is shared with echocardiologists in addition to that which is unique to critical care. The National Board of Echocardiography certification establishes that the physician has achieved the ability to independently perform and interpret critical care echocardiography at a standard recognized by critical care professional societies encompassing a wide spectrum of backgrounds. The interest shown and the success achieved on the CCEeXAM by practitioners of critical care echocardiography support the standards set by the National Board of Echocardiography for testamur status and certification in this imaging specialty area.

Objectives: Awareness of the impact of bedside ultrasound to reduce iatrogenic pneumothoraces while performing bedside pleural procedures has increased but with little understanding in how ultrasound is used for these procedures. Design and Setting: We conducted a retrospective chart review at a tertiary referral center in the United States from January 1, 2014, to March 31, 2017. Our study assessed adverse effect rates between real-time ultrasound-guided and ultrasound-marked thoracenteses and thoracostomy tube placements. Patients: Three-hundred ninety-four ICU patients were included in this study. Measurements and Main Results: There was a significant difference in the rate of adverse effects between real-time ultrasound-guided (0.63% [95% CI, 0.11–3.4%]) and ultrasound-marked (6.89% [95% CI, 4.15–11.24%]; p ≤ 0.01) procedures. More specifically, the rate of pneumothoraces was different between the two procedures (0.63% [95% CI, 0.11–3.4%] vs 4.43% [95% CI, 2.35–8.21%]; p = 0.02). In patients mechanically ventilated, there was a significant difference in overall adverse effect rates between groups of ultrasound use ( p = 0.01). Conclusions: The use of real-time ultrasound guidance was associated with a lower rate of iatrogenic pneumothoraces.

Background: Portopulmonary hypertension (POPH) is defined as pulmonary arterial hypertension (PAH) in the context of portal hypertension. Severe POPH has been considered an absolute contraindication of orthotopic liver transplantation (OLT).Objective: Since there are no definitive guidelines for the immediate preoperative, intraoperative, and postoperative evaluation and treatment of POPH patients, we have used published literature along with our experience to review current knowledge in this area.Summary: Moderate-to-severe POPH has important consequences in the perioperative management of candidates for OLT. Adequate right ventricular function is critical to survive the hemodynamic burden of OLT. Immediate preoperative assessment of hemodynamics; careful intraoperative monitoring and management of volume status, pressure changes, and ventricular function; and postoperative transitions of PAH-specific therapy are key components to successful OLT. We emphasize the advantages of the echocardiogram during all of these phases and stress the importance of a team approach to plan care and respond to the multiple challenges of OLT in POPH.