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The paradigm of supportive care of patients who are critically ill has changed significantly over the past 20 years. Patients on mechanical ventilation are no longer heavily sedated; the goal is a comfortable patient who can interact with health-care professionals and with their family members. Systematic, regular assessment of the patient for pain, anxiety, and sleep deprivation allows early recognition of these distressing symptoms. Appropriate treatment of patients' symptoms should be based on a multi-modal pharmacologic and non-pharmacologic approach. Early mobilization and avoidance of physical restraint are additional patient-centered goals. The presence of family members during daily rounds and at the bedside can reduce the distress of the patient and enhance communication with the health-care team. All of these changes have created new challenges and opportunities for the multidisciplinary health-care team. This review aimed to describe the main components of evidence-based supportive care of patients on mechanical ventilation, beyond the specific settings of the ventilator.

Purpose of review An increasing number of patients are placed on extracorporeal membrane oxygenation (ECMO) for respiratory or cardiac failure. Sound understanding of physiology and configuration of ECMO is essential for proper management. This review covers different monitoring parameters and tools for patients supported with different types of ECMO. Recent findings Emphasis is placed on monitoring saturations at different sites depending on type of ECMO support. The main monitoring tools detailed in this review are echocardiography and pulmonary artery catheters. Summary The review will help physicians better assess adequate ECMO support by using the appropriate parameters for each type of configuration.

Venoarterial (VA) and venovenous (VV) extracorporeal membrane oxygenation (ECMO) support is increasingly being used in recent years in the adult population. Owing to the underlying disease precipitating severe respiratory or cardiac failure, echocardiography plays an important role in the management of these patients. Nevertheless, there are currently no guidelines on the use of echocardiography in the setting of ECMO support. This review describes the current state of application of echocardiography for patients supported with both VA and VV ECMO.

Venoarterial (VA) and venovenous (VV) extracorporeal membrane oxygenation (ECMO) support is increasingly being used in recent years in the adult population. Owing to the underlying disease precipitating severe respiratory or cardiac failure, echocardiography plays an important role in the management of these patients. Nevertheless, there are currently no guidelines on the use of echocardiography in the setting of ECMO support. This review describes the current state of application of echocardiography for patients supported with both VA and VV ECMO. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-1042-2) contains supplementary material, which is available to authorized users.

Novel approaches to the management of acute respiratory distress syndrome include strategies to enhance alveolar liquid clearance, promote epithelial cell growth and recovery after acute lung injury, and individualize ventilator care on the basis of physiological responses. The use of extracorporeal membrane oxygenation (ECMO) is growing rapidly, and centers providing ECMO must strive to meet stringent quality standards such as those set out by the ECMONet working group. Prognostic tools such as the RESP score can assist clinicians in predicting outcomes for patients with severe acute respiratory failure but do not predict whether ECMO will enhance survival. Evidence continues to grow that novel modes of mechanical ventilation such as neurally adjusted ventilatory assist are feasible and improve patient physiology and patient-ventilator interaction; data on clinical outcomes are limited but supportive. Critical illness causes long-term psychological and function sequelae: the risk of a new psychiatric diagnosis and severe physical impairment is significantly increased in the months after discharge from the intensive care unit. These long-term effects might be amenable to changes in sedation practice and increased early mobilization. Daily sedation discontinuation enhances the validity of routine delirium assessment. Many critically ill patients merit assessment by palliative care clinicians; the demand for palliative care services among critically ill patients is expected to grow. Future trials to test therapies for critical illness must ensure that study designs are adequately powered to detect benefit using realistic event rates. Integrating "big data" approaches into treatment decisions and trial designs offers a potential means of individualizing care to enhance outcomes for critically ill patients.

OBJECTIVE: In an attempt to refine the indications for liver resection (LR) for highly symptomatic polycystic liver disease (PLD), we focused on the characteristics, technical difficulties, postoperative outcome, and long-term follow-up of PLD patients who underwent either LR or liver transplantation (LT). METHODS: Since 1995, among 72 patients with massive hepatomegaly, 45 patients underwent LR associated with contralateral cyst fenestration whereas 27 underwent LT associated with simultaneous kidney transplantations in 23. The LR group was characterized by absence of end-stage renal insufficiency, absence of ascites, and better nutrition status. In the LR group, the volumetry of the spared noncystic parenchyma was preoperatively assessed whereas pathological analysis focused on fibrosis and vascular congestion. RESULTS: After LR, the mortality was nil and overall morbidity was 71%, including biliary leak in 20% and ascites in 42%. Persistent and massive ascites was observed in 8 patients who have undergone extensive resection and had significantly more frequently fibrosis on the analysis of their resected surgical specimens (P = 0.002). A volume of the remnant noncystic parenchyma less than 30% and the presence of vascular changes on the specimen were associated with higher risk of complications. The 5-year survival was 95% and among the 43 survivors, after a mean follow-up of 41 months, 36 (83%) patients stated that they were satisfied, with complete relief of symptoms in 30 (70%). After LT, the postoperative mortality was 15% and the overall morbidity was 85%, including 12 patients who required reoperation. Severe complications were more frequent in the presence of denutrition and preoperative ascites. The 5-year survival was 85% and after a mean follow-up of 36 months all survivors had complete relief of symptoms due to hepatomegaly. CONCLUSIONS: In case of massive hepatomegaly from PLD without end-stage renal failure, LR should be considered first when preserved remnant liver volume represents at least 30% of the total volume liver in the absence of vascular changes or fibrosis.

Purpose To provide consensus, and a list of experts’ recommendations regarding the basic skills for head-to-toe ultrasonography in the intensive care setting. Methods The Executive Committee of the European Society of Intensive Care (ESICM) commissioned the project and supervised the methodology and structure of the consensus. We selected an international panel of 19 expert clinicians–researchers in intensive care unit (ICU) with expertise in critical care ultrasonography (US), plus a non-voting methodologist. The panel was divided into five subgroups (brain, lung, heart, abdomen and vascular ultrasound) which identified the domains and generated a list of questions to be addressed by the panel. A Delphi process based on an iterative approach was used to obtain the final consensus statements. Statements were classified as a strong recommendation (84% of agreement), weak recommendation (74% of agreement), and no recommendation (less than 74%), in favor or against. Results This consensus produced a total of 74 statements (7 for brain, 20 for lung, 20 for heart, 20 for abdomen, 7 for vascular Ultrasound). We obtained strong agreement in favor for 49 statements (66.2%), 8 weak in favor (10.8%), 3 weak against (4.1%), and no consensus in 14 cases (19.9%). In most cases when consensus was not obtained, it was felt that the skills were considered as too advanced. A research agenda and discussion on training programs were implemented from the results of the consensus. Conclusions This consensus provides guidance for the basic use of critical care US and paves the way for the development of training and research projects. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-021-06486-z.