Current Opinion in Critical Care

Anticoagulation reversal for intracranial hemorrhage in the era of the direct oral anticoagulants Purpose of review This review focuses on recent relevant literature that examines the reversal of direct oral anticoagulants (DOACs) in patients with intracranial hemorrhage (ICH). The aim of this review is to provide an insightful description of available reversal agents and their clinical utility. Recent findings Increases in prescribing of DOACs has led to the introduction of drug-specific reversal agents. The clinical trials that evaluated these agents did not include a comparator arm making it difficult to determine if they are clinically superior to nonspecific reversal agents. Summary Numerous options for reversal of DOAC-associated ICH are currently available. Recent clinical trials have demonstrated drug-specific reversal agents are effective in this setting, but additional research is needed to determine whether these agents should be routinely preferred over nonspecific reversal agents. Correspondence to Gretchen M. Brophy, Pharm.D., BCPS, FCCP, FCCM, FNCS, Pharmacotherapy and Outcomes Science and Neurosurgery, Virginia Commonwealth University, Medical College of Virginia Campus, School of Pharmacy, 410 N. 12th Street, Room 642, Richmond, VA 23298-0533, USA. Tel.: +1 804 828 1201;. fax: +1 804 828 0343; e-mail: gbrophy@vcu.edu Copyright © 2020 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Treatment targets based on autoregulation parameters in neurocritical care patients Purpose of review This review summarizes the physiological basis of autoregulation-oriented therapy in critically ill patients, with a particular emphasis on individual targets based on parameters that describe autoregulation of cerebral blood flow. Recent findings The concepts of optimal cerebral perfusion (CPPopt) and arterial pressures (ABPopt), which both take advantage of continuous measures of cerebral autoregulation, recently have been introduced into clinical practice. It is hypothesized that if both pressures are used as individual targets and followed, the incidence and severity of dysautoregulation will diminish sufficiently to improve outcomes across the spectrum of acute neurological illnesses. These parameters have not been tested in randomized trials. However, a Phase II trial for CPPopt in Traumatic Brain Injury (COGITATE) is underway. Clinical series suggest that delirium following cardiac surgery may be reduced if blood pressure is actively regulated above the lower limit of autoregulation. In traumatic brain injury, using CPPopt as a single target allows monitoring of the upper and lower limits of autoregulation that provide a well tolerated ‘corridor’ for treatment. Pilot studies in which ABPopt is monitored in preterm newborns suggest fewer haemorrhagic events if blood pressure is closer to its optimal target. Brain imaging studies suggest worse tissue outcomes when blood pressure is below ABPopt. Summary Targeted control of brain and systemic blood pressures to optimize cerebral autoregulation is of substantial interest to the neurocritical care and anaesthesia community, as this strategy may help to avoid secondary brain insults associated with ischemia or hyperaemia. The same strategy can be used outside the ICU (e.g. cardiac surgery, or in stroke patients after mechanical thrombectomy); this requires further research. Correspondence to Marek Czosnyka, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge University Hospitals, Biomedical Campus, Cambridge CB2 0QQ, UK. Tel: +44 1223 336946; e-mail: Mc141@medschl.cam.ac.uk Copyright © 2020 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Update on extracorporeal liver support Purpose of review Extracorporeal liver support (ELS) is a large unmet need in day-to-day hepatology practice. In an era of ever-improving outcomes with liver transplantation for very sick patients with either acute liver failure (ALF) or acute-on-chronic liver failure, the outcomes for similar patients who are ineligible for transplantation remains poor. Providing a bridge to recovery from these catastrophic conditions is the aim of ELS, and we aim to review the evidence to date of different ELS devices as well as look to the future of ELS device development. Recent findings Studies on different ELS devices shave been relatively consistent in their inability to demonstrate a survival benefit; however, recent published evidence has suggested ways in which the three key pillars to ELS – the disease (patient selection), device (ELS system), and dose (intensity) – may be modified to attain a more positive outcome. New devices are grasping these concepts and demonstrating encouraging preclinical results. Summary ELS devices to studied to date have not been able to significantly improve transplant-free survival. Newer ELS devices are currently in clinical trials and their results are awaited. Correspondence to Rajiv Jalan, Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, Pond Street, London NW3 2QG, UK. Tel: +011 44 2077 940500; e-mail: r.jalan@ucl.ac.uk Copyright © 2020 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Gastrointestinal and hepatic critical care: a domain of intensive care in evolution No abstract available

Evolution of neurocritical care No abstract available

Extracranial complications after traumatic brain injury: targeting the brain and the body Purpose of review The aim of this review is to provide an update on the pathophysiology and treatment of severe traumatic brain injury (TBI)-related complications on extracranial organs. Recent findings Extracranial complications are common and influence the outcome from TBI. Significant improvements in outcome in a sizeable proportion of patients could potentially be accomplished by improving the ability to prevent or reverse nonneurological complications such as pneumonia, cardiac and kidney failure. Prompt recognition and treatment of systemic complications is therefore fundamental to care of this patient cohort. However, the role of extracranial pathology often has been underestimated in outcome assessment since most clinicians focus mainly on intracranial lesions and injury rather than consider the systemic effects of TBI. Summary Robust evidence about pathophysiology and treatment of extracranial complications in TBI are lacking. Further studies are warranted to precisely understand and manage the multisystem response of the body after TBI. Correspondence to Giuseppe Citerio, MD, School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy. E-mail: giuseppe.citerio@unimib.it Giusepep Citerio Orcid ID: 0000-0002-5374-3161. Copyright © 2020 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Evaluation and management of intraabdominal hypertension Purpose of review The purpose of this review is to provide an overview of the pathophysiology of intraabdominal hypertension/compartment syndrome and to review the recent advances in the areas of evaluation and management of this disorder. Recent findings The incidence of intraabdominal hypertension (IAH) in intensive care units is as high as 45%, an incidence much higher than initially suspected. Despite decompressive laparotomy as a treatment, mortality in patients who developed abdominal compartment syndrome (ACS) requiring this procedure is as high as 50%. Some patients may be treated by fewer invasive methods, such as paracentesis, thereby avoiding the morbidity of laparotomy. Protective lung ventilation is key to managing the pulmonary sequalae of ACS. Point-of-care ultrasound can be used as an adjunctive decision-making tool. Summary IAH is common in critically ill patients and portends a high mortality rate. Prevention and early recognition are key in minimizing adverse events. Correspondence to Babak Sarani, MD, FACS, FCCM, 2150 Pennsylvania Ave., NW, Suite 6B, Washington, DC 20037, USA. Tel.: +1 202 741 3188;. fax: +1 202 741 3219; e-mail: bsarani@mfa.gwu.edu Copyright © 2020 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Evaluation and management of abdominal sepsis Purpose of review The review focuses on the evaluation and management of abdominal sepsis. Recent findings A multitude of surgical approaches towards abdominal sepsis are practized in the world and may be associated with significant morbidity and mortality rates. Despite decades of sepsis research, no specific therapies for sepsis have emerged. Without specific therapies, the management of abdominal sepsis is based on the control of the infection and organ support. Summary Early clinical diagnosis, adequate source control to stop ongoing contamination, appropriate antibiotic therapy dictated by patient and infection risk factors, and prompt resuscitation are the cornerstones of its management. Correspondence to Massimo Sartelli, Department of Surgery, Macerata Hospital, Macerata, Italy. Tel: +00 39 3405369701; fax: +00 39 07332572471; e-mail: massimosartelli@gmail.com Copyright © 2020 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Minimally invasive surgery for intracerebral hemorrhage Purpose of review Spontaneous intracerebral hemorrhage (ICH) is common, associated with a high degree of mortality and long-term functional impairment, and remains without effective proven treatments. Surgical hematoma evacuation can reduce mass effect and decrease cytotoxic effects from blood product breakdown. However, results from large clinical trials that have examined the role of open craniotomy have not demonstrated a significant outcome benefit over medical management. We review the data on minimally invasive surgery (MIS) that is emerging as a treatment modality for spontaneous ICH. Recent findings The use of MIS for supratentorial ICH has increased significantly in recent years and appears to be associated with decreased mortality and improved functional outcome compared with medical management. The role of MIS for posterior fossa ICH is ill-defined. Currently available MIS devices allow for stereotactic aspiration and thrombolysis, endoport-mediated evacuation, and endoscopic aspiration. Clinical series demonstrate that MIS can facilitate significant hematoma volume reduction and may be associated with less morbidity than conventional open surgical approaches. Summary MIS is an appealing treatment modality for supratentorial ICH and with careful patient selection and technologic advances has the potential to improve neurologic outcomes and reduce mortality. Early and extensive hematoma evacuation are important therapeutic targets and current studies are underway that have the potential to change the management for ICH patients. Correspondence to J. Claude Hemphill III, MD, MAS, Department of Neurology, Zuckerberg San Francisco General Hospital, Building 1, Room 101, 1001 Potrero Avenue, San Francisco, CA 94110, USA. Tel: +1 628 206 3213; e-mail: claude.hemphill@ucsf.edu Copyright © 2020 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Update on nutritional assessment and therapy in critical care Purpose of review To summarize recent data regarding nutritional assessment and interventions in the ICU. Recent findings Current methods to assess nutritional risk do not allow identification of ICU patients who may benefit from specific nutritional intervention. Early full energy delivery does not appear to improve outcomes at the population level. Specific nutrient composition of formula has been shown to improve glycemic outcomes in patients with hyperglycemia but patient-centered outcomes are unaffected. Summary Based on recent studies, full energy feeding early during critical illness has no measurable beneficial effect, and may even be harmful, when applied to entire populations. The mechanisms underlying this are unknown and remain proposed theories. Tools to assess nutritional risk in the ICU that identify patients who will benefit from a specific nutritional intervention are lacking. The optimal composition of feeds, and indications for specific interventions for enteral feeding intolerance remain uncertain. Correspondence to Annika Reintam Blaser, Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia. Tel: +372 5142281; e-mail: annika.reintam.blaser@ut.ee Copyright © 2020 YEAR Wolters Kluwer Health, Inc. All rights reserved.