So all right, so I'm going to be talking about peritransplant and GI considerations. This is going to be quick I don't think we have a lot of time but the full length of the guidelines is you know easily found online and all of our Methodology as well as you know, what went into our decision making is all very transparent and found, you know in the supplement to our guidelines So I have no relevant disclosures a shout out to all of the authors and especially our vice chairs Dean and Waleed, you know who were instrumental in sort of, you know, helping us complete the guidelines and getting them published So a brief overview of methodology or all of the questions were in Pico format There was a systematic review of the literature for every question You know for every included study we did a risk of bias Assessment then used meta-analytic techniques to summarize the evidence and we used the great methodology to guide Both the assessment of our quality of evidence and the strength of our recommendations and again, our Recommendations are either strong or conditional and when they're strong we say we recommend and when they're conditional we say we suggest Okay. So moving on to the GI considerations our first big question was Should be in people who have acute on chronic liver failure should we recommend performing endoscopy within 12 hours of presentation and we recommended that Performing Endoscopy no later than 12 hours of presentation and critically ill patients with ACLF and portal hypertensive bleeding. This was actually a Best practice statement and the reason it was a best practice statement was because there was no prospective data but you know when you when we Looked at physiological considerations and especially that ACLF itself is sometimes triggered by GI bleeding We thought that endoscopy would lead to faster cessation of the bleeding source prevent hemodynamic instability and other complications And so the panel voted strongly to recommend early endoscopy and that is within 12 hours of presentation our next speaker question pertained to the use of proton pump inhibitors in portal hypertensive bleeding and again, this was So, you know our guidelines had very few strong recommendations. So these are some of the questions that we actually You know strongly recommended based on the evidence or their decision making of the panel and so in case of proton pump inhibitors We recommended using proton pump inhibitors and critically ill Acute on chronic liver failure patients with portal hypertensive bleeding and this was a very strong recommendation However, there was low quality of evidence and and the reason there was low quality of evidence was that you know, there was no direct There was not very much direct evidence and in in people with ACLF, but there were three meta-analysis that found That the use of PPI is in portal hypertensive bleeding reduces the risk of Rebleeding but really did not have very much of an impact on mortality And the are we downgraded the level of evidence because the inclusion of retrospective because of the inclusion of retrospective studies in all of these meta-analysis and the high risk of bias from non standardized inclusion and treatment criteria and But when we extrapolated evidence from the non-medical cohorts We issued a strong recommendation for you know for for the speaker question the next speaker question was the use of Octotide or somatostatin analogs and portal hypertensive bleeding and we recommended that we strongly recommended using octotide or somatostatin analogs For treatment of portal hypertensive bleeding and critically in patients with acute on chronic liver failure This was a strong recommendation and there was moderate quality of evidence and based on our systematic review of prospective trials we found that these that the use of somatostatin analogs was actually associated with a Substantially lower risk of mortality and you know when we calculated it out. It was 30 fewer deaths per 1,000 patients The next speaker question was You know was Pertained to the use of tips or trans jugular intra hepatic portal systemic shunt placement in patients in critically ill acute on chronic liver failure patients with the recurrent variceal bleeding And here we suggested which is now again the this is a conditional recommendation with low quality of evidence We suggested the use of trans jugular Intra hepatic portal systemic shunt for recurrent variceal bleeding after medical and endoscopic intervention But you know over continued endoscopic therapy and but however we qualified this Recommendation saying that you know tips requires appropriate screening and this intervention also requires Access to an experienced operator at a center with expertise and our rationale was that you know tips It was associated with significant decreases of mortality and bleeding rates at one year However, it also causes hepatic encephalopathy and so in patients with you know significant about against philopathy It should be considered on a case-by-case basis Our final Pico question on in our In the GI subsection was whether we should recommend large volume paracentesis and critically ill patients with ACLF and And 10 societies and we and this was again a best practice statement and we did recommend performing large volume Paracentesis with measurement of intra abdominal pressure in critically ill patients with ACLF with 10 societies And intra abdominal hypertension or hemodynamic renal or respiratory compromise and again the rationale for this You know the reason it was a best practice statement was that you know We could not find any randomized or prospective data to guide our recommendations However, when you look again, you know, there was a strong very strong physiological rationale, you know, there are obviously draining ascites especially 10 societies and critically ill patients low and especially in people who have intra abdominal head hypertension lowers the intra-abdominal pressure and in heterogeneous critically ill patients Relief of intra abdominal hypertension is associated with improved organ function Okay moving on to peritransplant considerations the our first speaker question was in deceased liver graft donors should we recommend administration of corticosteroids again conditional recommendation very low quality of evidence We suggested using systemic steroids for deceased liver Graft donors and the rationale for this was that if you look at brain dead donors Results from pooled RCTs demonstrated, you know a about a 5% absolute risk reduction of liver Graft dysfunction in those receiving corticosteroids Our next speaker question was pertained to the use of balanced crystalloid solutions perioperatively and liver transplant recipients and we suggested the use of balanced or normal clary chloremic crystalloid solutions over hyper chloremic saline for peritransplant liver fluid liver for Peritransplant fluid replacement and liver transplant recipients again conditional recommendation low quality of evidence There was nothing that actually there was no direct evidence in liver transplant recipients But in heterogeneous critically ill patients, you know, there is possibly a reduction in mortality and major advance major adverse kidney events with the use of balance solutions The next speaker question pertained to the use of Albumin in the intraoperative period and again, we suggested the use of albumin over crystalloid for intraoperative volume Replacement again, this was a conditional recommendation and there was you know, pretty low quality of evidence again, no direct evidence for Liver transplantation, but you know using again using indirect evidence. We found that albumin may be beneficial our final Pico question that we Actually issued a recommendation for was pertain to the use of extra corporeal liver support and prop, you know, probably the most controversial Recommendation. So we we suggested using either using extra corporeal liver support or Standard medical therapy and critically ill ALF or ACLF patients and this was a conditional recommendation very low quality of evidence We qualified the statement saying, you know providers may choose to use artificial liver support based on local availability familiarity with its use and available resources and The rationale for this was that if you look at pool data, you know from about 24 randomized control trials And if you look at ACLF and ALF together, there is a small mortality benefit But if you analyze them separately, you know, neither is statistically significant and you know, these therapies Require expertise you have limited access and there is a high cost and so, you know They should only be used in the you know Hands of people who sort of know how to use them and are familiar with their use and have expertise there were a few questions in the perioperative group that week where there was insufficient evidence to Issue a recommendation in the those questions were the use of the donor rule risk index and liver liver allografts the choice of intra intraoperative hemodynamic monitoring the use of Peri transfer period peri-transplant fluid restrictions with vasopressors and the early extubation So we just couldn't issue a recommendation because we could find absolutely no evidence pertaining to these questions, so that is it for both the GI and And peri-transplant recommendations. I will now hand this over to my co-chair Ram who's going to talk about neurology and ID recommendations

acute-on-chronic liver failure

portal hypertensive bleeding

endoscopy

somatostatin analogs

transjugular intrahepatic portal systemic shunt