Management of swallowing disorders in ICU patients - A multinational expert opinion.

BACKGROUND: Dysphagia is common in intensive care unit (ICU) patients, yet it remains underrecognized and often unmanaged despite being associated with life-threatening complications, prolonged ICU stays and hospitalization. PURPOSE: To propose an expert opinion for the diagnosis and management of dysphagia developed from evidence-based clinical recommendations and practitioner insights. METHODS: A multinational group of dysphagia and critical care experts conducted a literature review using a modified ACCORD methodology. Based on a fusion of the available evidence and the panel's clinical experience, an expert opinion on best practice management was developed. RESULTS: The panel recommends adopting clinical algorithms intended to promote standardized, high-quality care that triggers timely systematic dysphagia screening, assessment, and treatment of extubated and tracheostomized patients in the ICU. CONCLUSIONS: Given the lack of robust scientific evidence, two clinical management algorithms are proposed for use by multidisciplinary teams to improve early systematic detection and effective management of dysphagia in ICU patients. Additionally, emerging therapeutic options such as neurostimulation have the potential to improve the quality of ICU dysphagia care.

Liver transplantation for acute-on-chronic liver failure predicts post-transplant mortality and impaired long-term quality of life.

BACKGROUND: Among patients with cirrhosis, candidate selection and timing of liver transplantation (LT) remain problematic. Acute-on-chronic liver failure (ACLF) is a severe complication of cirrhosis with excessive short-term mortality rates under conservative therapeutic measures. The role of LT in the management of ACLF is uncertain. OBJECTIVE: To assess the impact of ACLF on post-LT survival and long-term graft function, morbidity and quality of life (QoL). METHODS: We retrospectively analysed all cirrhosis patients undergoing LT at our institution between 01/2009 and 12/2014. Median follow-up was 8.7 years. Long-term LT survivors were interviewed with established QoL questionnaires. RESULTS: Of 250 LT recipients, 98 fulfilled the EASL diagnostic ACLF criteria before LT ('ACLF-LT'). ACLF associated with reduced post-LT survival (HR for 6-month survival compared to non-ACLF-LT: 0.18; HR for 10-year-survival: 0.47; both P < .001) depending on ACLF severity before LT, and mainly inferred by infections both in the early and late phases after LT. In ACLF patients, CLIFc-OFs was superior to MELD score in predicting post-LT mortality. Long-term follow-up revealed comparable graft functions and comorbidity burden in ACLF-LT and non-ACLF-LT survivors. ACLF-LT patients reported significantly impaired health and QoL, particularly with regards to anxiety/depression and physical and psychological health (all P < .05). LabMELD score, presence of ACLF at LT and duration of post-LT intensive care associated with poor long-term QoL. CONCLUSION: ACLF predicts impaired post-LT survival. While long-term graft function and extrahepatic comorbidities are comparable in ACLF and non-ACLF LT survivors, the strikingly low QoL in many ACLF-LT recipients warrants consideration during follow-up patient care.

Alveolar recruitment strategy and high positive end-expiratory pressure levels do not affect hemodynamics in morbidly obese intravascular volume-loaded patients.

We evaluated the effect of the alveolar recruitment strategy and high positive end-expiratory pressure (PEEP) on hemodynamics in 20 morbidly obese (body mass index 50 +/- 9 kg/m2), intravascular volume-loaded patients undergoing laparoscopic surgery. The alveolar recruitment strategy was sequentially performed with and without capnoperitoneum and consisted of an upward PEEP trial, recruitment with 50-60 cm H2O of plateau pressure for 10 breaths, and a downward PEEP trial. Recruitment and high PEEP did not cause significant disturbances in any hemodynamic variable measured by systemic and pulmonary artery catheters. Transesophageal echocardiography revealed no differences in end-diastolic areas or evidence of segmental abnormalities in wall motion.

Monitoring of whole-body hyperthermia with transesophageal echocardiography (TEE).

UNLABELLED: Hyperthermia induces tumor cell death by a spectrum of tumor tissue changes. As whole-body hyperthermia (WBH) can cause cardiovascular complications, especially when cardiotoxic cytostatic agents are administered, invasive cardiovascular monitoring during WBH is necessary. WBH requires a great deal of expenditure and bears the risk of severe toxicity. Furthermore cardiovascular stress, alterations of cardiac index and systemic vascular resistance are major problems during WBH. The purpose of this prospective study was to evaluate cardiovascular changes in patients undergoing WBH under general anesthesia using transesophageal echocardiography (TEE) with special focus on left ventricular function. METHODS: Hemodynamic parameters were measured with standard monitoring and TEE at defined time points in 20 patients (ASA III) undergoing WBH: M37 (baseline, body temperature: 37 degrees C) after induction of anesthesia, M39 during warming up (39 degrees C), M41.8 at plateau level (41.8 degrees C), M38 during cooling period (38 degrees C). RESULTS: Invasive monitoring and TEE measurements showed signs of hyperdynamic circulation with significant increase of the heart rate (73.6 +/- 13.7 min(-1) (M37), 104.6 +/- 13.0 min(-1) (M41.8)) and significant decrease of mean blood pressure (74.9 +/- 15.3 mmHg (M37), 65.3 +/- 11.2 mmHg (M41.8)). Cardiac index (CI) nearly doubled and stroke volume index (SVI) increased significantly from M37 to M41.8. Cardiac contractility, fractional area change (FAC) and ejection fraction (EF) increased. At M38 CI, SVI, FAC and EF showed a tendency to decrease compared to M41.8 but remained elevated compared to M37. CONCLUSION: Patients undergoing WBH showed typical signs of hyperdynamic circulation without impairment of left ventricle which could be monitored excellently by TEE. We recommend using TEE especially in patients with an increased cardiac risk.