Summary
Background
Acute‐on‐chronic liver failure (ACLF) is a severe complication of liver cirrhosis associated with excess short‐term mortality rates. Orthotopic liver transplantation (OLT) is a ...potentially life‐saving therapeutic modality for acute‐on‐chronic liver failure patients, but selection of transplant candidates with an acceptable post‐transplant outcome is difficult.
Aim
To assess the risk of liver transplantation in patients with ACLF, and to determine parameters that predict post‐transplant survival in this patient cohort.
Methods
We retrospectively analysed all 250 patients with cirrhosis who underwent their first liver transplantation between 2009 and 2014 at our institution, and assessed post‐transplant outcomes.
Results
Of 250 cirrhotic liver transplant recipients, 98 patients fulfilled the diagnostic criteria for acute‐on‐chronic liver failure in the 3‐month pre‐transplant period. Compared to non‐ACLF patients, ACLF was associated with significantly higher short‐term morbidity and mortality after liver transplantation (90‐day patient survival 96.1% non‐ACLF vs 72.4% ACLF patients, P < 0.0001). Clinical improvement in the pre‐transplant period, as defined by recovery of at least one previously failed organ system, was observed in 37 of 98 acute‐on‐chronic liver failure patients, mostly within several days after diagnosis. Most notably, clinical improvement prior to liver transplantation was associated with excellent post‐transplant survival rates that approximated non‐ACLF transplant recipients. Following the 90‐day post‐transplant period, patient survival and long‐term graft functions were comparable between ACLF and non‐ACLF liver transplant recipients for up to 5 years.
Conclusions
Acute‐on‐chronic liver failure predicts adverse outcome after orthotopic liver transplantation. Given the dismal prognosis without transplantation, however, our results indicate that ACLF patients can be transplanted with comparably good outcomes, in particular patients who improve under conservative therapeutic measures.
Linked ContentThis article is linked to Izzy and Watt, and Huebener et al papers. To view these articles visit https://doi.org/10.1111/apt.14679 and https://doi.org/10.1111/apt.14804.
Nanoparticle formation in flames is strongly influenced by the residence-time–temperature history inside the flame. We study how the temperature history can be intentionally modified by orienting ...flames either in an upward-firing or downward-firing configuration. We also investigate the influence of unintended residence-time modifications caused by sampling nozzles. These phenomena are investigated by experiments and simulations for the synthesis of iron oxide nanoparticles from premixed iron-pentacarbonyl-doped hydrogen/oxygen flat flames. The experiments apply molecular-beam sampling with a particle mass spectrometer to measure particle sizes and a quartz microbalance to detect the presence of condensed matter. The simulations rely on a finite-rate chemistry approach with species-specific diffusion, particle dynamics are described by a bi-modal population balance model. It is demonstrated that the downward-burning flame forms a detached stagnation point, causing longer residence times at elevated temperature than an upward- or horizontally firing flame, permitting the growth of larger particles. These iron oxide particles are eventually formed in the recombination zone of the flame, but no condensed matter was found in the reaction zone. The experiments also observed the formation of particles in the preheat zone, but their composition and all aspects of their disappearance remain uncertain. Current models do, however, suggest the formation of iron particles and their subsequent evaporation and combustion.
Background
Percutaneous dilatational tracheostomy (PDT) in critically ill patients is often led by optical guidance with a bronchoscope. This is not without its disadvantages. Therefore, we aimed to ...study the feasibility of a recently introduced endotracheal tube‐mounted camera (VivaSight™‐SL, ET View, Misgav, Israel) in the guidance of PDT.
Methods
We studied 10 critically ill patients who received PDT with a VivaSight‐SL tube that was inserted prior to tracheostomy for optical guidance. Visualization of the tracheal structures (i.e., identification and monitoring of the thyroid, cricoid, and tracheal cartilage and the posterior wall) and the quality of ventilation (before puncture and during the tracheostomy) were rated on four‐point Likert scales. Respiratory variables were recorded, and blood gases were sampled before the interventions, before the puncture and before the insertion of the tracheal cannula.
Results
Visualization of the tracheal landmarks was rated as ‘very good’ or ‘good’ in all but one case. Monitoring during the puncture and dilatation was also rated as ‘very good’ or ‘good’ in all but one. In the cases that were rated ‘difficult’, the visualization and monitoring of the posterior wall of the trachea were the main concerns. No changes in the respiratory variables or blood gases occurred between the puncture and the insertion of the tracheal cannula.
Conclusion
Percutaneous dilatational tracheostomy with optical guidance from a tube‐mounted camera is feasible. Further studies comparing the camera tube with bronchoscopy as the standard approach should be performed.
Since December 2019, the novel coronavirus SARS-CoV-2 (Severe Acute Respiratory Syndrome - Corona Virus-2) has been spreading rapidly in the sense of a global pandemic. This poses significant ...challenges for clinicians and hospitals and is placing unprecedented strain on the healthcare systems of many countries. The majority of patients with Coronavirus Disease 2019 (COVID-19) present with only mild symptoms such as cough and fever. However, about 6 % require hospitalization. Early clarification of whether inpatient and, if necessary, intensive care treatment is medically appropriate and desired by the patient is of particular importance in the pandemic. Acute hypoxemic respiratory insufficiency with dyspnea and high respiratory rate (> 30/min) usually leads to admission to the intensive care unit. Often, bilateral pulmonary infiltrates/consolidations or even pulmonary emboli are already found on imaging. As the disease progresses, some of these patients develop acute respiratory distress syndrome (ARDS). Mortality reduction of available drug therapy in severe COVID-19 disease has only been demonstrated for dexamethasone in randomized controlled trials. The main goal of supportive therapy is to ensure adequate oxygenation. In this regard, invasive ventilation and repeated prone positioning are important elements in the treatment of severely hypoxemic COVID-19 patients. Strict adherence to basic hygiene, including hand hygiene, and the correct wearing of adequate personal protective equipment are essential when handling patients. Medically necessary actions on patients that could result in aerosol formation should be performed with extreme care and preparation.
Compared to other countries, Germany has the highest number of intensive care unit (ICU) beds, but, despite this, a shortage in ICU care is evident. Currently, little comprehensive data on ICU ...staffing and on subsequent closure of ICU beds are available. The current survey therefore aimed to systematically investigate the closure of ICU beds.
A survey was performed among authorized professional trainers in ICU medicine.
Overall, a shortage of ICU beds following bed closure was evident in 76% of all ICU floors with 22% reporting daily ICU bed closure. In 47%, two ICU beds were not available. Emergency care was unrestricted in only 18%, while restrictions were reportedly frequent or even constant in 30%. The main reasons for ICU bed closure were the unavailability of ICU nurses (44%) and the co-existing unavailability of nurses and physicians (19%). On average, the nurse/patient ratio was 1:2.5 in the morning, 1:2.6 in the afternoon, and 1:3.1 in the night shift.
ICU bed closure regularly occurs in Germany. The underlying main reason has been identified to be the unavailability of ICU nursing staff. This is suggested to directly interfere with emergency care. For this reason, an action plan is urgently needed.
Addition of inhaled iloprost to bosentan may have beneficial effects in patients with idiopathic pulmonary arterial hypertension (IPAH). A multicentre, open, randomised, controlled trial was ...performed to assess the safety and efficacy of inhaled iloprost in patients with IPAH who had already been treated with bosentan. The trial was terminated early after a futility analysis predicted failure with respect to the predetermined sample size. At that time, 40 patients were randomised to receive either bosentan alone (control group) or bosentan plus inhaled iloprost (combination group) for a 12-week period. The primary end-point, change in 6-min walking distance, was not met (mean changes +1 m and -9 m in the control and combination group, respectively). These results may have been skewed by three outliers in the iloprost group who presented with severe clinical worsening. None of the secondary end-points including functional class, peak oxygen uptake, and time to clinical worsening differed significantly between groups. The current study failed to show a positive effect of adding inhaled iloprost to bosentan in idiopathic pulmonary arterial hypertension patients. Further studies involving larger sample sizes and long-term follow-up are needed to determine the efficacy of adding inhaled iloprost to bosentan in patients with idiopathic pulmonary arterial hypertension.
When patients with chronic obstructive lung disease (COPD) and acute on chronic respiratory insufficiency fail non-invasive ventilation (NIV) they are commonly intubated and treated with invasive ...mechanical ventilation (IMV) to ensure adequate gas exchange. However, IMV itself is associated with considerable complications which can aggravate any pre-existing lung disease and contribute to morbidity and mortality. When lung protective ventilation fails or cannot be maintained, full or partial extracorporeal lung assist (ECLA) is increasingly used to provide oxygenation and/or carbon dioxide removal. This can rescue patients' lives, help resting their lungs until recovery or transplantation or even avoiding intubation and IMV in the first place. Recent technological improvements of extracorporeal devices have made ECLA more efficient and safe. This article discusses different types of ECLA, their potential indications in patients with COPD as well as the preliminary clinical evidence for their effectiveness and safety.
In acute respiratory insufficiency, oxygenation and/or ventilation support by mechanical ventilation is an integral part of intensive care and emergency medicine. Effective airway management is ...essential to prevent hypoxic complications during the securing of the airway. This includes for example the recognition of difficult airways and adequate pre-oxygenation. While the laryngeal tube can be used in the context of cardiopulmonary resuscitation in emergency medicine, endotracheal intubation is standard in intensive care medicine. In addition to direct laryngoscopy (DL), indirect laryngoscopy using video laryngoscopy (VL) is also available. Compared to DL, advantages in intubation success, anticipated difficult airways, and a reduction of mucosa damage have been shown for VL, whereas the advantage for intubation success could only be demonstrated for experienced physicians who should always be present due to the potential complications of intubation. With regard to mortality and incidence of hypoxia, no difference between DL and VL could be shown. According to current data, the VL should not be used preclinically. A tracheostomy is often performed for long-term ventilation. It is still unclear which patients benefit from an early tracheostomy. Usually the bed-side percutaneous dilatation tracheostomy technique is used, which is often performed under bronchoscopic guidance.
Against the background of the pandemic caused by infection with the SARS-CoV-2, the German Society for Pneumology and Respiratory Medicine (DGP e.V.), in cooperation with other associations, has ...designated a team of experts in order to answer the currently pressing questions about therapy strategies in dealing with COVID-19 patients suffering from acute respiratory insufficiency (ARI).The position paper is based on the current knowledge that is evolving daily. Many of the published and cited studies require further review, also because many of them did not undergo standard review processes.Therefore, this position paper is also subject to a continuous review process and will be further developed in cooperation with the other professional societies.This position paper is structured into the following five topics:1. Pathophysiology of acute respiratory insufficiency in patients without immunity infected with SARS-CoV-22. Temporal course and prognosis of acute respiratory insufficiency during the course of the disease3. Oxygen insufflation, high-flow oxygen, non-invasive ventilation and invasive ventilation with special consideration of infectious aerosol formation4. Non-invasive ventilation in ARI5. Supply continuum for the treatment of ARIKey points have been highlighted as core statements and significant observations. Regarding the pathophysiological aspects of acute respiratory insufficiency (ARI), the pulmonary infection with SARS-CoV-2 COVID-19 runs through three phases: early infection, pulmonary manifestation and severe hyperinflammatory phase.There are differences between advanced COVID-19-induced lung damage and those changes seen in Acute Respiratory Distress Syndromes (ARDS) as defined by the Berlin criteria. In a pathophysiologically plausible - but currently not yet histopathologically substantiated - model, two types (L-type and H-type) are distinguished, which correspond to an early and late phase. This distinction can be taken into consideration in the differential instrumentation in the therapy of ARI.The assessment of the extent of ARI should be carried out by an arterial or capillary blood gas analysis under room air conditions and must include the calculation of the oxygen supply (measured from the variables of oxygen saturation, the Hb value, the corrected values of the Hüfner number and the cardiac output). In principle, aerosols can cause transmission of infectious viral particles. Open systems or leakage systems (so-called vented masks) can prevent the release of respirable particles. Procedures in which the invasive ventilation system must be opened, and endotracheal intubation must be carried out are associated with an increased risk of infection.The protection of personnel with personal protective equipment should have very high priority because fear of contagion must not be a primary reason for intubation. If the specifications for protective equipment (eye protection, FFP2 or FFP-3 mask, gown) are adhered to, inhalation therapy, nasal high-flow (NHF) therapy, CPAP therapy or NIV can be carried out according to the current state of knowledge without increased risk of infection to the staff. A significant proportion of patients with respiratory failure presents with relevant hypoxemia, often also caused by a high inspiratory oxygen fraction (FiO2) including NHF, and this hypoxemia cannot be not completely corrected. In this situation, CPAP/NIV therapy can be administered under use of a mouth and nose mask or a respiratory helmet as therapy escalation, as long as the criteria for endotracheal intubation are not fulfilled.In acute hypoxemic respiratory insufficiency, NIV should be performed in an intensive care unit or in a comparable unit by personnel with appropriate expertise. Under CPAP/NIV, a patient can deteriorate rapidly. For this reason, continuous monitoring with readiness to carry out intubation must be ensured at all times. If CPAP/NIV leads to further progression of ARI, intubation and subsequent invasive ventilation should be carried out without delay if no DNI order is in place.In the case of patients in whom invasive ventilation, after exhausting all guideline-based measures, is not sufficient, extracorporeal membrane oxygenation procedure (ECMO) should be considered to ensure sufficient oxygen supply and to remove CO
.
There has been increasing use of invasive techniques, such as extracorporeal organ support, in intensive care units (ICU), and declining autopsy rates. Thus, new measures are needed to maintain ...high-quality standards. We investigated the potential of computed tomography (CT)-based virtual autopsy to substitute for medical autopsy in this setting.
We investigated the potential of virtual autopsy by post-mortem CT to identify complications associated with medical devices in a prospective study of patients who had died in the ICU. Clinical records were reviewed to determine the number and types of medical devices used, and findings from medical and virtual autopsies, related and unrelated to the medical devices, were compared.
Medical and virtual autopsies could be performed in 61 patients (Group M/V), and virtual autopsy only in 101 patients (Group V). In Group M/V, 41 device-related complications and 30 device malpositions were identified, but only with a low inter-method agreement. Major findings unrelated to a device were identified in about 25% of patients with a high level of agreement between methods. In Group V, 8 device complications and 36 device malpositions were identified.
Device-related complications are frequent in ICU patients. Virtual and medical autopsies showed clear differences in the detection of complications and device malpositions. Both methods should supplement each other rather than one alone for quality control of medical devices in the ICU. Further studies should focus on the identification of special patient populations in which virtual autopsy might be of particular benefit.
NCT01541982.
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