It's a real pleasure to be with you. Also, I'd like to thank the Education Committee. I chair this committee. I work with a phenomenal group of very talented and motivated people who are listed here in this slide. I'd like to thank them for their contributions to this collective work. I have no disclosures. Today, I will be presenting literature from the following topics as it pertains to adult critical care. Sepsis. The Blues Group performed a study of beta-D-glucan as a marker of a fungal infection or invasive cannabinoid infection. They looked at therapy directed by cultures compared to therapy directed by this marker. They found that there was no improvement in 28-day mortality when they used the marker. The Lee Group studied the effect of focused cardiopulmonary ultrasound in the resuscitation of patients with septic shock. When they compared these patients to patients who received standard care, they found there was no difference in 28-day mortality despite using ultrasound to direct resuscitation. However, these patients had enjoyed a shorter duration of vasopressor support, but by 24 and 72 hours received similar amounts of fluid. The Drury Group looked at therapeutic hyperthermia in patients with sepsis. In this Washington University and University of Iowa collaborative, they looked at patients with sepsis who had a temperature less than 38.3. They externally warmed these patients for 48 hours to a goal temperature of 1.5 degrees higher than their lowest documented temperature. Although there was no difference in several biomarkers that were studied, the patients in the study group had a lower 28-day mortality, notably 18% compared to 43% in the standard group, and they also had more free hospital days. Multi-organ dysfunction. The Shaheed Group looked at the impact of sepsis on multi-organ dysfunction. In this University of Florida study, patients who screened positive for sepsis if they went on to have multi-organ dysfunction were noted to have the highest mortality compared to patients without multi-organ dysfunction, and their mortality was approximately 48%. Nutrition. The Marler Group, which was out of the University of Kansas, performed a retrospective review from 2010 to 2020. They looked at elder patients who experienced trauma, and they looked at patients specifically who underwent surgical feeding tube placement. Their mortality was 7% after feeding tube placement and 20% by 90 days. Those that died were more likely to have dementia, heart failure, and end-stage liver disease. The McCart Group looked at improving enteral nutrition in trauma and surgical patients in the intensive care unit. They performed a prospective study from 2016 to 2020, and they looked at the outcome of patients who received an enhanced protocol for feeding, specifically focused on the timely initiation of enteral feeds, as well as volume-based feeding accommodating for interruptions in therapy. And they found, when compared to standard therapy, that 85% versus 75% reached their primary outcome of feeds at least 80% to goal. The Comfor Group published guidelines in a form of a 30-page document based on Aspen guidelines previously published that reviewed a number of questions in the literature. Specifically, they focused on higher versus lower energy, higher versus lower protein, and isochloric parenteral versus enteral nutrition. What they found was that there was no significant difference in many of the outcomes for the questions studied, but they did stress that they were changing their recommendation for energy to be 12 to 25 kcals per kilo per day. And they emphasized avoiding overfeeding with parenteral nutrition. Hemodynamics. The Messina Group, which was a multinational study, looked at fluid challenges in critically ill patients. This study was performed in Italy, France, and Chile, and it served as a meta-analysis of approximately 124 studies over a 10-year time. They studied over 6,000 patients who received fluid challenges and found that the average volume was about 500 mLs, and in most cases, crystalloid was used. When compared to patients from previous years, the 2011 to 2021 decade represented patients who received boluses over a shorter period of time and boluses more frequently made of crystallite. The Kalinas Group looked at echocardiography in the hemodynamics of critically ill patients. They looked at the right ventricular outflow track, VTI, or velocity time integral, and they found that there was moderately consistent studies performed at the bedside when compared to the left side. They felt that adding the subcostal window allowed for better monitoring in patients on the ventilator. In the Gustiniano Group, which studied echo in prone patients, the group reported their experience of performing standard echo versus echo in the prone position, and they felt that by tilting the probe, they could obtain a five-chamber apical view, which facilitated reasonably good analysis. Thrombosis. The Tan Group looked at splenctic venous thrombosis in a retrospective study in Australia. They identified 164 patients. 64% of them had portal venous thrombosis. By 90 days, they reached a mortality of 20%, and in most cases, the cause was non-hematologic. Transfusion. Oh, I'm sorry. Could I go back one slide? This is my second most favorite paper of the year, so we can't miss it. The Bunch Group looked at the immunothrombotic complications of COVID-19 in surgical patients. They reviewed the evidence that has been generated during the course of the pandemic, and they felt that there was now clear evidence demonstrating the fibrinolytic shutdown that patients experience with hyper and hypocoagulable states in immunothrombotic crosstalk that affected surgical patients adversely. They made recommendations for the timing of elective surgery, and they recommended that emergent procedures occur on as usual, on usual timing. However, for elective procedures, the timing should be delayed based on the severity of COVID illness. Delayed by four weeks for patients who were essentially asymptomatic without respiratory symptoms, to a delay of 12 weeks for patients who were critically ill and required an intensive care unit. Transfusion. The Dorkin Group looked at platelets and FFP in balanced transfusion in patients who received a massive transfusion. This study was performed at the Mass General Hospital, as well as Leiden University in the Netherlands. In this five-year database study, they looked at 9,215 patients who received a massive transfusion. They found that for patients with FFP and platelet transfusion, that a balanced transfusion lowered the mortality rate to the lowest possible level. When patients did not receive platelets or FFP in a balanced fashion, the mortality rate rose. And for patients who did not receive either platelets or FFP in their transfusion, they suffered the greatest mortality. In the Carson Group, the Carson Group studied transfusion thresholds that guide red blood cell transfusion. They performed a meta-analysis in hospitals in the United States and in the UK. They found that a restrictive transfusion protocol reduced the risks of transfusion by 41%, but there was no impact on 30-day mortality. The Adeboye Group looked at the effect of age of the red cells on outcomes. They found that of the 31,497 patients that they studied, that patients who did not have severely impaired renal function, they would tolerate up to 10 units of red blood cell transfusion without any impact on renal function. The Endo Group looked at the clinical benefits of early use of cryo and plasma compared to plasma alone in patients bleeding after trauma. They found a slightly lower mortality in the 1,959 patients who received a combination of cryo and FFP as compared to FFP alone. There was only a 4% difference in these groups, but it was felt to be significant. Fluids. The Russell Group, which was part of the Prepare II Investigator Group and the Pragmatic Critical Care Research Group, randomized 1,067 patients undergoing tracheal intubation to receive a fluid bolus prior to intubation. They found that there was no difference in cardiovascular collapse in the patients who received the fluid bolus prior to intubation. The Jones Group. The Jones Group put out a guideline document based on the French Society of Anesthesia and Intensive Care Medicine Consensus. They reported that gelatin should not be used in resuscitation, and they also did not recommend colloid in resuscitation in keeping with current American practices. The Myhoff Group, which was part of the Classic Trial Group, was an international randomized trial of patients in septic shock. They found that for patients who received at least one liter of IV fluid and then were randomized to a restrictive practice versus a standard fluid resuscitation practice, that there was no improvement in mortality at 90 days with a restrictive practice. Acute respiratory failure. The Fossli Group looked at the effects of prone position on lung recruitment in patients with COVID-19 infection. Using electrical impedance tomography, they found that prone patients enjoyed improved lung recruitment, decreased adelect trauma, and improved VQ matching. The Cohn Group studied tracheostomy practices in patients with COVID-19. These patients who were on VVECMO were part of a retrospective study. They found that tracheostomy was performed at similar rates before and during the COVID pandemic, but with COVID, they found that patients were trached later when they were on ECMO. They also noted that tracheostomy increased patient mobilization, but did not improve mortality. COVID-19. The Perkins Group, along with the RecoveryRS Collaboration, performed a randomized clinical trial of patients with respiratory failure in 48 hospitals in the United Kingdom. They randomized patients to receive CPAP, high-flow oxygen, or conventional oxygen. They found that patients who received CPAP therapy enjoyed a significant reduction in their risk of intubation and mortality. There was no difference between high-flow oxygen and conventional oxygen. The World Health Organization Solidarity Trial Consortium looked at remdesivir in patients with COVID-19. They found that there was a small effect against death and progression to ventilation in patients who received remdesivir. Acute renal failure. The Schneck Group studied the delta-like canonical notch ligand in predicting sepsis and acute kidney injury in surgical patients. This study looked at 20 septic patients, 20 cardiac surgery patients, and 20 matched controls. They found that the plasma levels of this ligand were significantly elevated in patients with sepsis, and that it might serve as a useful future biomarker. The Narangroj Group looked at renal outcomes according to renal replacement therapy. They found in this randomized trial that patients did not experience a difference in, excuse me, patients did not experience a difference in renal replacement therapy dependence at 28 days, regardless of hemodialysis versus CRRT. Acute liver failure. The Mywild Group performed a randomized controlled trial of cirrhotic patients who received albumin resuscitation in the setting of sepsis-associated hypotension. While these patients experienced a faster improvement in hemodynamics and a faster lactic acid clearance, they did not have an improvement in survival, and they did have a higher rate of pulmonary complications. The IROD Group looked at restrictive intraoperative fluid intake in patients undergoing liver surgery and the effect on post-surgical renal function. In this study of 397 liver resection patients, post-op acute kidney injury occurred in 133 out of the 397 patients. A liberal strategy for fluid administration was associated with a lower risk of post-operative acute kidney injury. Those who had acute kidney injury had longer hospital stays and higher mortality. In the Saliba Group, artificial liver support patients were studied, and in this publication, authors reviewed albumin dialysis for the short-term support of patients with acute liver failure. Traumatic brain injury. The Okonkwo Group looked at brain oxygenation optimization in patients with severe traumatic brain injury. They found that ICP and brain tissue oxygenation monitoring reduced brain tissue hypoxia, and these patients trended towards a lower mortality. The McCree Group looked at the functional outcomes over the first year of patients who had moderate to severe brain trauma. This was a study performed in 18 level one trauma centers in between 2014 and 2018. They found that 19% of severe TBI patients and 32% of moderate TBI patients reported no disability at 12 months, and they cautioned clinicians in making early definitive prognostic statements suggesting poor outcomes in this patient population. Acute heart failure. The Wayne Group looked at predicting and recognizing right heart failure in their patient population. This review described the effect of LVAD implantation on right heart function. The Heidenreich Group published the 2022 guidelines, which was a joint guideline publication for the AHA, the ACC, and the HFSA, looking at heart failure and replacing the 2013 and 2017 guidelines. Adrenal insufficiency. The Wentworth Group published a review of adrenal insufficiency in decompensated liver failure patients, focusing on testing, spectrum of impairment, and the relative deficiency in times of stress. Rehabilitation. The Dean Group looked at neuropsychiatric assessment and management of patients who survived critical care. This review focused on the neuropsychiatric aspects of post-intensive care unit in ICU survivors. The Inouye Group looked at the prevalence and long-term prognosis of patients with post-intensive care syndrome and sepsis. They found that more than half of survivors had post-intensive care unit at three and six months. Those who developed post-intensive care unit after three months had a lower survival at two years. The Zbar Group looked at the socioecologic perspective of barriers complicating the recovery of patients with post-intensive care unit syndrome. They found that there was a lack of enthusiasm due to the absence of institutional mitigation protocols and a general frustration in providers who cared for these patients who were unable to close the gap between academic recommendations and operationalizing interventions. And lastly, communication. The Erickson Group looked at communication quality in the intensive care unit, and they found that less than half of conversations achieved the standard of care of bidirectional communication proficiency. They recommended scheduled conversations which had higher levels of good quality communication and recommended avoiding unscheduled conversations. With that, I'd like to thank the Education Committee of the Surgery Section and the Society for the opportunity to speak today. Thank you.

adult critical care

sepsis

multi-organ dysfunction

nutrition

hemodynamics