Cartin‐Ceba, Rodrigo

Objective: Peripherally inserted central catheters are a popular means of obtaining central venous access in critically ill patients. However, there is limited data regarding the rapidity of the peripherally inserted central catheter procedure in the presence of acute illness or obesity, both of which may impede central venous catheter placement. We aimed to determine the feasibility, safety, and duration of peripherally inserted central catheter placement in critically ill patients, including obese patients and patients in shock. Methods: This retrospective cohort study was performed using data on 55 peripherally inserted central catheters placed in a 30-bed multidisciplinary intensive care unit in Mayo Clinic Hospital, Phoenix, Arizona. Information on the time required to complete each step of the peripherally inserted central catheter procedure, associated complications, and patient characteristics was obtained from a prospectively assembled internal quality assurance database created through random convenience sampling. Results: The Median Procedure Time, beginning with the first needle puncture and ending when the procedure is complete, was 14 (interquartile range: 9–20) min. Neither critical illness nor obesity resulted in a statistically significant increase in the time required to complete the peripherally inserted central catheter procedure. Three (5.5%) minor complications were observed. Conclusion: Critical illness and obesity do not delay the acquisition of vascular access when placing a peripherally inserted central catheter. Concerns of delayed vascular access in critically ill patients should not deter a physician from selecting a peripherally inserted central catheter to provide vascular access when it would otherwise be appropriate.

Objectives: To develop evidence-based recommendations for clinicians caring for adults with acute or acute on chronic liver failure in the ICU. Design: The guideline panel comprised 29 members with expertise in aspects of care of the critically ill patient with liver failure and/or methodology. The Society of Critical Care Medicine standard operating procedures manual and conflict-of-interest policy were followed throughout. Teleconferences and electronic-based discussion among the panel, as well as within subgroups, served as an integral part of the guideline development. Setting: The panel was divided into nine subgroups: cardiovascular, hematology, pulmonary, renal, endocrine and nutrition, gastrointestinal, infection, perioperative, and neurology. Interventions: We developed and selected population, intervention, comparison, and outcomes questions according to importance to patients and practicing clinicians. For each population, intervention, comparison, and outcomes question, we conducted a systematic review aiming to identify the best available evidence, statistically summarized the evidence whenever applicable, and assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence to decision framework to facilitate recommendations formulation as strong or conditional. We followed strict criteria to formulate best practice statements. Measurements and Main Results: In this article, we report 29 recommendations (from 30 population, intervention, comparison, and outcomes questions) on the management acute or acute on chronic liver failure in the ICU, related to five groups (cardiovascular, hematology, pulmonary, renal, and endocrine). Overall, six were strong recommendations, 19 were conditional recommendations, four were best-practice statements, and in two instances, the panel did not issue a recommendation due to insufficient evidence. Conclusions: Multidisciplinary international experts were able to formulate evidence-based recommendations for the management acute or acute on chronic liver failure in the ICU, acknowledging that most recommendations were based on low-quality indirect evidence.

Introduction Diarrhoea is a frequent concern in the intensive care unit (ICU) and is associated with prolonged mechanical ventilation, increased length of ICU stay, skin breakdown and renal dysfunction. However, its prevalence, aetiology and prognosis in the critically ill have been poorly studied. The primary objectives of this study are to determine the incidence, risk factors and consequences of diarrhoea in critically ill adults. The secondary objectives are to estimate the incidence of Clostridium difficile- associated diarrhoea (CDAD) in ICU patients and to validate the Bristol Stool Chart and Bliss Stool Classification System characterising bowel movements in the ICU. Our primary outcome is the incidence of diarrhoea . Our secondary outcomes include: CDAD, ICU and hospital mortality and ICU and hospital length of stay. Methods and analysis This international prospective cohort study will enrol patients over 10 weeks in 12 ICUs in Canada, the USA, Poland and Saudi Arabia. We will include all patients 18 years of age and older who are admitted to the ICU for at least 24 hours and follow them daily until ICU discharge. Our primary outcome is the incidence of diarrhoea based on the WHO definition, during the ICU stay. Our secondary outcomes include: CDAD, ICU and hospital mortality and ICU and hospital length of stay. We will use logistic regression to identify factors associated with diarrhoea (as defined using WHO criteria) and the kappa statistic to measure agreement on diarrhoea rates between the WHO definition and the Bristol Stool Chart and Bliss Stool Classification System. Ethics and dissemination The protocol has been approved by the research ethics board of all participating centres. The diarrhoea interventions, consequences and epidemiology in the intensive care unit (DICE-ICU) study will generate evidence about diarrhoea and its frequency, predisposing factors and consequences, to inform critical care practice and future research. Lay summary Diarrhoea is a frequent clinical problem for hospitalised patients including those who are critically ill in the ICU. Diarrhoea can cause complications such as skin damage, dehydration and kidney problems. It is not clear how common diarrhoea is in the ICU, the factors that cause it or the best way for clinicians to assess it. The DICE-ICU study is an international prospective observational study to examine the frequency, risk factors and outcomes of diarrhoea during critical illness.

Pulmonary artery hypertension (PAH) that occurs as a consequence of portal hypertension is termed portopulmonary hypertension (POPH) and is associated with significant morbidity and mortality. Among liver transplant (LT) candidates, reported incidence rates of POPH range from 4.5% to 8.5%. The severity of POPH is unrelated to the severity of portal hypertension or the liver disease. In LT patients, intraoperative death and immediate post-LT mortality are feared clinical events when transplantation is attempted in the setting of untreated, moderate to severe POPH. Specific pulmonary artery vasodilator medications (PAH-specific therapy) appear effective in reducing pulmonary artery pressures, improving right ventricular (RV) function and survival. Thus, screening for and accurately diagnosing POPH prior to LT has become a standard of care. The post-LT course of patients with moderate POPH is unpredictable, but most patients can be weaned from PAH-specific therapy over time. In this article, we present an overview of the preoperative assessment of POPH with an emphasis on risk assessment for transplant and the most recent medical treatment options.

In patients with portopulmonary hypertension (n = 13) included in the 12‐week randomized placebo‐controlled PATENT‐1 trial, riociguat was well tolerated and improved 6‐min walking distance (6MWD), World Health Organization functional class (WHO FC), and other efficacy parameters; 6MWD and WHO FC improvements were sustained over two years in the open‐label extension, PATENT‐2.