Critical Care

Severe infections in neurocritical care Purpose of review We have highlighted the recent advances in infection in neurocritical care. Recent findings Central nervous system (CNS) infections, including meningitis, encephalitis and pyogenic brain infections represent a significant cause of ICU admissions. We underwent an extensive review of the literature over the last several years in order to summarize the most important points in the diagnosis and treatment of severe infections in neurocritical care. Summary Acute brain injury triggers an inflammatory response that involves a complex interaction between innate and adaptive immunity, and there are several factors that can be implicated, such as age, genetic predisposition, the degree and mechanism of the injury, systemic and secondary injury and therapeutic interventions. Neuroinflammation is a major contributor to secondary injury. The frequent and challenging presence of fever is a common denominator amongst all neurocritical care patients. Correspondence to Ignacio Martin-Loeches, Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, PO Box 580, James's Street, Dublin 8, Ireland. E-mail: drmartinloeches@gmail.com Copyright © 2020 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Priorities in peritonitis Purpose of the review Timely and adequate management are the key priorities in the care of peritonitis. This review focuses on the cornerstones of the medical support: source control and antiinfective therapies Recent findings Peritonitis from community-acquired or healthcare-associated origins remains a frequent cause of admission to the ICU. Each minute counts for initiating the proper management. Late diagnosis and delayed medical care are associated to dramatically increased mortality rates. The diagnosis of peritonitis can be difficult in these ICU cases. The signs of organ failures are more relevant than biological surrogates. A delayed source control and a late anti-infective therapy are of critical importance. The quality of source control and medical management are other key elements of the prognosis. The conventional rules applied for sepsis are applicable for peritonitis, including hemodynamic support and anti-infective therapy. Growing proportions of multidrug resistant pathogens are reported from surgical samples, mainly related to Gram-negative bacteria. The increasing complexity in the care of these critically ill patients is a strong incentive for a multidisciplinary approach. Summary Early clinical diagnosis, timely and adequate source control and antiinfective therapy are the essential pillars of the management of peritonitis in ICU patients. Correspondence to Philippe Montravers, MD, PhD, Anesthesiology and Critical Care Medicine, CHU Bichat-Claude Bernard, 46 Rue Henri Huchard, 75018 Paris, France. Tel: +33140256024; e-mail: philippe.montravers@aphp.fr Copyright © 2020 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Rehabilitating the neurological patient in the ICU: what is important? Purpose of review To describe recent literature evaluating the effectiveness of early rehabilitation in neurocritical care patients. Recent findings There is a drive for early rehabilitation within the ICU; however, there are unique considerations for the neurocritically ill patient that include hemiplegia, cognitive impairments and impaired conscious state that can complicate rehabilitation. Additionally, neurological complications, such as hemorrhage expansion and cerebral edema can lead to the risk of further neurological damage. It is, therefore, important to consider the effect of exercise and position changes on cerebral hemodynamics in patients with impaired cerebral autoregulation. There is a paucity of evidence to provide recommendations on timing of early rehabilitation postneurological insult. There are also mixed findings on the effectiveness of early mobilization with one large, multicenter RCT demonstrating the potential harm of early and intensive mobilization in stroke patients. Conversely, observational trials have found early rehabilitation to be well tolerated and feasible, reduce hospital length of stay and improve functional outcomes in neurological patients admitted to ICU. Summary Further research is warranted to determine the benefits and harm of early rehabilitation in neurological patients. As current evidence is limited, and given recent findings in stroke studies, careful consideration should be taken when prescribing exercises in neurocritically ill patients. Correspondence to Carol L. Hodgson, Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, 3004, Australia. Tel: +61 448674532; e-mail: Carol.hodgson@monash.edu Copyright © 2020 YEAR Wolters Kluwer Health, Inc. All rights reserved.

A clinical approach to acute mesenteric ischemia Purpose of review To summarize current evidence on acute mesenteric ischemia (AMI) in critically ill patients, addressing pathophysiology, definition, diagnosis and management. Recent findings A few recent studies showed that a multidiscipliary approach in specialized centers can improve the outcome of AMI. Such approach incorporates current knowledge in pathophysiology, early diagnosis with triphasic computed tomography (CT)-angiography, immediate endovascular or surgical restoration of mesenteric perfusion, and damage control surgery if transmural bowel infarction is present. No specific biomarkers are available to detect early mucosal injury in clinical setting. Nonocclusive mesenteric ischemia presents particular challenges, as the diagnosis based on CT-findings as well as vascular management is more difficult; some recent evidence suggests a possible role of potentially treatable stenosis of superior mesenteric artery and beneficial effect of vasodilator therapy (intravenous or local intra-arterial). Medical management of AMI is supportive, including aiming of euvolemia and balanced systemic oxygen demand/delivery. Enteral nutrition should be withheld during ongoing ischemia-reperfusion injury and be started at low rate after revascularization of the (remaining) bowel is convincingly achieved. Summary Clinical suspicion leading to tri-phasic CT-angiography is a mainstay for diagnosis. Diagnosis of nonocclusive mesenteric ischemia and early intestinal injury remains challenging. Multidisciplinary team effort may improve the outcome of AMI. Correspondence to Annika Reintam Blaser, Department of Anaesthesiology and Intensive Care, University of Tartu, Puusepa 8, Tartu 51014, Estonia. Tel: +372 5142281; e-mail: annika.reintam.blaser@ut.ee Copyright © 2020 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Prevention of gastrointestinal bleeding in critically ill patients Purpose of review This review focuses on the current literature on the epidemiology and prevention of stress-induced clinically important gastrointestinal bleeding in ICU patients. Recent findings The incidence of stress-induced clinically important gastrointestinal bleeding in critically ill patients seems to be decreasing. Observational studies and an exploratory randomized controlled trial suggest that early enteral nutrition may be effective in preventing gastrointestinal bleeding in patients who are not at high risk. Recent systemic reviews and meta-analyses indicate that proton pump inhibitors and H2 receptor antagonists are more effective than placebo in preventing clinically important gastrointestinal bleeding, especially in high-risk and very high-risk patients, but do not reduce mortality. Although observational data suggested an association of proton pump inhibitors and H2 receptor antagonists with Clostridium difficile infection and pneumonia, this association was not confirmed in randomized controlled trials. Summary The incidence of stress-induced clinically important gastrointestinal bleeding in critically ill patients seems to have decreased over time. Even though stress ulcer prophylaxis in critically ill patients has been a research focus for decades, many questions remain unanswered, such as which groups of patients are likely to benefit and what pharmacologic agent is associated with the best benefit-to-harm ratio. Correspondence to Yaseen M. Arabi, MD, FCCP, FCCM, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, and Intensive Care Department, King Abdulaziz Medical City, ICU2, Mail Code 1425, PO Box 22490, Riyadh 11426, Saudi Arabia. Tel: +966 118011111 x18855; e-mail: arabi@ngha.med.sa Copyright © 2020 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Overcoming challenges to enteral nutrition delivery in critical care Purpose of review Existing data and all ICU nutrition guidelines emphasize enteral nutrition (EN) represents a primary therapy leading to both nutritional and non-nutritional benefits. Unfortunately, iatrogenic malnutrition and underfeeding is virtually ubiquitous in ICUs worldwide for prolonged periods post-ICU admission. Overcoming essential challenges to EN delivery requires addressing a range of real, and frequently propagated myths regarding EN delivery. Recent findings Key recent data addresses perceived challenges to EN including: Adequately resuscitated patients on vasopressors can and likely should receive trophic early EN and this was recently associated with reduced mortality;Patients paralyzed with neuromuscular blocking agents can and should receive early EN as this was recently associated with reduced mortality/hospital length of stay;Proned patients can safely receive EN;All ICU nutrition delivery, including EN, should be objectively guided by indirect calorimetry (IC) measures. This is now possible with the new availability of a next-generation IC device. Summary It is the essential implementation of this new evidence occurs to overcome real and perceived EN challenges. This data should lead to increased standardization/protocolization of ICU nutrition therapy to ensure personalized nutrition care delivering the right nutrition dose, in the right patient, at the right time to optimize clinical outcome. Correspondence to Paul E. Wischmeyer, MD, EDIC, FASPEN, FCCM, Professor of Anesthesiology and Surgery, Duke University School of Medicine DUMC, Box 3094 Mail # 41; 2301 Erwin Road, 5692 HAFS, Durham, North Carolina 27710, United States. Tel: +919 681 6646; e-mail: Paul.Wischmeyer@duke.edu Copyright © 2020 YEAR Wolters Kluwer Health, Inc. All rights reserved.

How do we identify the crashing traumatic brain injury patient – the neurosurgeon's view Purpose of review To provide an overview on recent advances in the field of assessment and monitoring of patients with severe traumatic brain injury (sTBI) in neurocritical care from a neurosurgical point of view. Recent findings In high-income countries, monitoring of patients with sTBI heavily relies on multimodal neurocritical parameters, nonetheless clinical assessment still has a solid role in decision-making. There are guidelines and consensus-based treatment algorithms that can be employed in both absence and presence of multimodal monitoring in the management of patients with sTBI. Additionally, novel dynamic monitoring options and machine learning-based prognostic models are introduced. Currently, the acute management and treatment of secondary injury/insults is focused on dealing with the objective evident pathology. An ongoing paradigm shift is emerging towards more proactive treatment of neuroworsening as soon as premonitory signs of deterioration are detected. Summary Based on the current evidence, serial clinical assessment, neuroimaging, intracranial and cerebral perfusion pressure and brain tissue oxygen monitoring are key components of sTBI care. Clinical assessment has a crucial role in identifying the crashing patient with sTBI, especially from a neurosurgical standpoint. Multimodal monitoring and clinical assessment should be seen as complementary evaluation methods that support one another. Correspondence to Jussi P. Posti, Neurocenter, Department of Neurosurgery, Turku University Hospital, P.O. Box 52, FI-20521 Turku, Finland. Tel: +358 2 313 0282, fax: +358 2 313 3052, e-mail: jussi.posti@utu.fi Copyright © 2020 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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