Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines.

To provide evidence-based guidelines for early enteral nutrition (EEN) during critical illness. We aimed to compare EEN vs. early parenteral nutrition (PN) and vs. delayed EN. We defined "early" EN as EN started within 48 h independent of type or amount. We listed, a priori, conditions in which EN is often delayed, and performed systematic reviews in 24 such subtopics. If sufficient evidence was available, we performed meta-analyses; if not, we qualitatively summarized the evidence and based our recommendations on expert opinion. We used the GRADE approach for guideline development. The final recommendations were compiled via Delphi rounds. We formulated 17 recommendations favouring initiation of EEN and seven recommendations favouring delaying EN. We performed five meta-analyses: in unselected critically ill patients, and specifically in traumatic brain injury, severe acute pancreatitis, gastrointestinal (GI) surgery and abdominal trauma. EEN reduced infectious complications in unselected critically ill patients, in patients with severe acute pancreatitis, and after GI surgery. We did not detect any evidence of superiority for early PN or delayed EN over EEN. All recommendations are weak because of the low quality of evidence, with several based only on expert opinion. We suggest using EEN in the majority of critically ill under certain precautions. In the absence of evidence, we suggest delaying EN in critically ill patients with uncontrolled shock, uncontrolled hypoxaemia and acidosis, uncontrolled upper GI bleeding, gastric aspirate >500 ml/6 h, bowel ischaemia, bowel obstruction, abdominal compartment syndrome, and high-output fistula without distal feeding access

EDUCATION Case Scenario: Postoperative Liver Failure after Liver Resection in a Cirrhotic Patient

H EPATIC resection for malignant liver tumors improves overall survival. However, liver surgery continues to be associated with significant morbidity and mortality. 1 A combination of careful patient selection, meticulous operative technique and specialized perioperative care is required to achieve low perioperative mortality (less than 5%) even in cases of hepatocellular carcinoma resections in cirrhotic patients. 1 Postoperative hepatic failure (POLF) is one of the most serious complications following liver surgery with a mortality that can exceed 70%. 2 The aim of this case scenario is to highlight the perioperative management of POLF after liver resection for hepatocellular carcinoma in patient with cirrhosis. Case Reports A 51-yr-old man with hepatocellular carcinoma in the setting of hepatitis B cirrhosis was scheduled for a right hepatectomy. He had been diagnosed with chronic hepatitis B 6 yr ago and had no other significant medical conditions. A rise in ␣-fetoprotein to 700 ng/ml led to the diagnosis of two hepatocellular carcinoma tumors in the right liver (60 mm in segment VII and 25 mm in segment IV and VIII) delineated on computed tomography (CT) scanning. Preoperative assessment did not show esophageal varices, portal hypertension, ascites, or evidence of portal vein thrombosis on abdominal CT-scan. Nontumor liver biopsy displayed macronodular cirrhosis. Bone scintigraphy and lung CTscan did not show any evidence of metastasis. Preoperative liver and kidney functions were normal. There was no evidence of ongoing hepatitis B viral replication. An arterial chemoembolization of the segment IV artery was performed first, followed by a right venous portal embolization to induce hypertrophy of the left liver 1 month later. 3 Four weeks after embolization, a postprocedure liver CT-scan showed a 10% increase in the volume of the left liver, suggesting that the postoperative remaining liver volume would be approximately 40% of the original liver volume. A right hepatectomy (resection of hepatic segments V, VI, VII, and VIII) was performed 6 weeks after portal embolization. Anesthesia consisted of propofol, sufentanil, atracurium, and desflurane. Perioperative hemodynamic monitoring was performed with a radial artery catheter, a right internal jugular catheter and esophageal doppler. Intermittent portal clamping lasted 34 min. There were no intraoperative complications and no red cell transfusions were required. The patient was extubated in the operating theater and then transferred to the intensive care unit as part of standard postoperative care. The patient was alert and hemodynamically stable, without respiratory or renal failure. Postoperative analgesia was provided through patient-controlled analgesia with morphine. Acetaminophen was not given. Immediate postoperative data showed metabolic acidosis with hyperlactatemia (4 mM), which normalized after 12 h. Postoperatively, bilirubinemia increased steadily and prothrombin time (PT) remained low (vitamin K had been supplemented)

Type I interferon signaling in systemic immune cells from patients with alcoholic cirrhosis and its association with outcome.

In immune cells, constitutively and acutely produced type I interferons (IFNs) engage autocrine/paracrine signaling pathways to induce IFN-stimulated genes (ISGs). Enhanced activity of IFN signaling pathways can cause excessive inflammation and tissue damage. We aimed to investigate the poorly known ISG expression in systemic immune cells from patients with decompensated alcoholic cirrhosis and its association with outcome.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

Hydrocortisone and fludrocortisone for prevention of hospital-acquired pneumonia in patients with severe traumatic brain injury (Corti-TC): a double-blind, multicentre phase 3, randomised placebo-controlled trial

International audienc

Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines

To provide evidence-based guidelines for early enteral nutrition (EEN) during critical illness.status: publishe

PACMAN trial protocol, Perioperative Administration of Corticotherapy on Morbidity and mortality After Non-cardiac major surgery: a randomised, multicentre, double-blind, superiority study

International audienceIntroduction Postoperative complications are major healthcare problems and are associated with a reduced short-term and long-term survival after surgery. An excessive postoperative inflammatory response participates to the development of postoperative infection and mortality. The aim of the Perioperative Administration of Corticotherapy on Morbidity and mortality After Non-cardiac surgery (PACMAN) study is to assess the effectiveness of perioperative administration of corticosteroid to reduce postoperative morbidity and mortality in patients undergoing major non-cardiac surgery.Methods and analysis The PACMAN is a multicentre, randomised, controlled, double-blind, superiority, two-arm trial of 1222 high-risk patients aged 50 years or older undergoing major non-cardiac surgery at 32 acute care hospital in France. Patients are randomly assigned to dexamethasone (0.2 mg/kg at the end of the surgical procedure and at day +1, n=611) or to placebo (n=611). The primary outcome is a composite of predefined 14-day major pulmonary complications and mortality. Secondary outcomes are surgical complications, infections, organ failures, critical care-free days, length of hospital stay and all-cause mortality at 28 days.Ethics and dissemination The PACMAN trial protocol has been approved by the ethics committee of Sud Mediterranée V, and will be carried out according to the Good Clinical Practice guidelines and the principles of the Declaration of Helsinki. The PACMAN trial is a randomised controlled trial powered to investigate whether perioperative administration of corticosteroids in patients undergoing non-cardiac major surgery reduces postoperative complications. The results of this study will be disseminated through presentation at scientific conferences and publication in peer-reviewed journals

Effect of Noninvasive Ventilation on Tracheal Reintubation Among Patients With Hypoxemic Respiratory Failure Following Abdominal Surgery: A Randomized Clinical Trial

International audienceIMPORTANCE: It has not been established whether noninvasive ventilation (NIV) reduces the need for invasive mechanical ventilation in patients who develop hypoxemic acute respiratory failure after abdominal surgery.OBJECTIVE: To evaluate whether noninvasive ventilation improves outcomes among patients developing hypoxemic acute respiratory failure after abdominal surgery.DESIGN, SETTING, AND PARTICIPANTS: Multicenter, randomized, parallel-group clinical trial conducted between May 2013 and September 2014 in 20 French intensive care units among 293 patients who had undergone abdominal surgery and developed hypoxemic respiratory failure (partial oxygen pressure \textless60 mm Hg or oxygen saturation [SpO2] ≤90% when breathing room air or \textless80 mm Hg when breathing 15 L/min of oxygen, plus either [1] a respiratory rate above 30/min or [2] clinical signs suggestive of intense respiratory muscle work and/or labored breathing) if it occurred within 7 days after surgical procedure.INTERVENTIONS: Patients were randomly assigned to receive standard oxygen therapy (up to 15 L/min to maintain SpO2 of 94% or higher) (n = 145) or NIV delivered via facial mask (inspiratory pressure support level, 5-15 cm H2O; positive end-expiratory pressure, 5-10 cm H2O; fraction of inspired oxygen titrated to maintain SpO2 ≥94%) (n = 148).MAIN OUTCOMES AND MEASURES: The primary outcome was tracheal reintubation for any cause within 7 days of randomization. Secondary outcomes were gas exchange, invasive ventilation-free days at day 30, health care-associated infections, and 90-day mortality. RESULTS: Among the 293 patients (mean age, 63.4 [SD, 13.8] years; n=224 men) included in the intention-to-treat analysis, reintubation occurred in 49 of 148 (33.1%) in the NIV group and in 66 of 145 (45.5%) in the standard oxygen therapy group within+ 7 days after randomization (absolute difference, -12.4%; 95% CI, -23.5% to -1.3%; P = .03). Noninvasive ventilation was associated with significantly more invasive ventilation-free days compared with standard oxygen therapy (25.4 vs 23.2 days; absolute difference, -2.2 days; 95% CI, -0.1 to 4.6 days; P = .04), while fewer patients developed health care-associated infections (43/137 [31.4%] vs 63/128 [49.2%]; absolute difference, -17.8%; 95% CI, -30.2% to -5.4%; P = .003). At 90 days, 22 of 148 patients (14.9%) in the NIV group and 31 of 144 (21.5%) in the standard oxygen therapy group had died (absolute difference, -6.5%; 95% CI, -16.0% to 3.0%; P = .15). There were no significant differences in gas exchange.CONCLUSIONS AND RELEVANCE: Among patients with hypoxemic respiratory failure following abdominal surgery, use of NIV compared with standard oxygen therapy reduced the risk of tracheal reintubation within 7 days. These findings support use of NIV in this setting. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT0197189

When Is a Critically Ill Cirrhotic Patient Too Sick to Transplant? Development of Consensus Criteria by a Multidisciplinary Panel of 35 International Experts.

BackgroundCritically ill cirrhotic patients are increasingly transplanted, but there is no consensus about futile liver transplantation (LT). Therefore, the decision to delay or deny LT is often extensively debated. These debates arise from different opinions of futility among transplant team members. This study aims to achieve a multinational and multidisciplinary consensus on the definition of futility in LT and to develop well-articulated criteria for not proceeding with LT due to futility.MethodsThirty-five international experts from anesthesiology/intensive care, hepatology, and transplant surgery were surveyed using the Delphi method. More than 70% of similar answers to a question were necessary to define agreement.ResultsThe panel recommended patient and graft survival at 1 year after LT to define futility. Severe frailty and persistent fever or <72 hours of appropriate antimicrobial therapy in case of ongoing sepsis were considered reasons to delay LT. A simple assessment of the number of organs failing was considered the most appropriate way to decide whether LT should be delayed or denied, with respiratory, circulatory and metabolic failures having the most influence in this decision. The thresholds of severity of organ failures contraindicating LT for which a consensus was achieved were a Pao2/FiO2 ratio<150 mm Hg, a norepinephrine dose >1 μg/kg per minute and a serum lactate level >9 mmol/L.ConclusionsOur expert panel provides a consensus on the definition of futile LT and on specific criteria for postponing or denying LT. A framework that may facilitate the decision if a patient is too sick for transplant is presented