The patient with severe traumatic brain injury: clinical decision-making: the first 60 min and beyond Purpose of review There is an urgent need to discuss the uncertainties and paradoxes in clinical decision-making after severe traumatic brain injury (s-TBI). This could improve transparency, reduce variability of practice and enhance shared decision-making with proxies. Recent findings Clinical decision-making on initiation, continuation and discontinuation of medical treatment may encompass substantial consequences as well as lead to presumed patient benefits. Such decisions, unfortunately, often lack transparency and may be controversial in nature. The very process of decision-making is frequently characterized by both a lack of objective criteria and the absence of validated prognostic models that could predict relevant outcome measures, such as long-term quality and satisfaction with life. In practice, while treatment-limiting decisions are often made in patients during the acute phase immediately after s-TBI, other such severely injured TBI patients have been managed with continued aggressive medical care, and surgical or other procedural interventions have been undertaken in the context of pursuing a more favorable patient outcome. Given this spectrum of care offered to identical patient cohorts, there is clearly a need to identify and decrease existing selectivity, and better ascertain the objective criteria helpful towards more consistent decision-making and thereby reduce the impact of subjective valuations of predicted patient outcome. Summary Recent efforts by multiple medical groups have contributed to reduce uncertainty and to improve care and outcome along the entire chain of care. Although an unlimited endeavor for sustaining life seems unrealistic, treatment-limiting decisions should not deprive patients of a chance on achieving an outcome they would have considered acceptable. Correspondence to Jeroen T.J.M. van Dijck, MD, Department of Neurosurgery, Leiden University Medical Center Albinusdreef 2, J-11-R-83 2333ZA, Leiden, The Netherlands. Tel: +31 71 5266987; e-mail: j.t.j.m.van_dijck@lumc.nl Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Caring for the surgical patient with limited ICU resources Purpose of review The current review aims to discuss the management of surgical patients in an ICU in countries where resources are limited. Recent findings ICU beds in low-income and middle-income countries (LMICs) are limited and also have limited human and structural resources. The working force has been described to be the costliest factor. Nevertheless, costs for intensive care in LMICs are one third from the cost reported from high-income countries. Alternative options have been described, so intensive care can be delivered outside ICU. Examples are Rapid-Response Systems and Medical Emergency Teams. Summary The care of the surgical patients in an intensive care setting in countries with resource limitations should be optimized, protocols for standardized care implemented and Better research and resource allocation, as well as investment in healthcare training are essential for the development of intensive care in LMICs is necessary. Correspondence to Marcelo A.F. Ribeiro Jr, MD, MSc, PhD, FACS, Chief of Acute Care and Trauma Surgery, Hospital Moriah, Avenida Aratãs 200, São Paulo 04081000, SP, Brazil. Tel: +55 11 968439911; e-mail: drmribeiro@gmail.com Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Emergency bedside ultrasound: benefits as well as caution – part 1. General Purpose of review The use of bedside or point-of-care ultrasound (POCUS) in medical emergencies is rapidly becoming more established as an effective acute diagnostic tool. The purpose of this review is to provide an overview of the various techniques currently used that are readily available, as well as several in development. Possible caveats are also addressed. Recent findings Despite its widespread use, definitive studies demonstrating improved patient outcomes are limited. The list of indications for POCUS nonetheless is increasing as practitioners acknowledge clinical benefits, and technological advancement improves diagnostic accuracy and efficiency of use. Summary We believe that a core level of POCUS should be achievable by practicing clinicians. Ultimately, the integration of POCUS findings into a patient management strategy must be holistic, and hence requires prudent consideration of the clinical scenario. Correspondence to Manu L.N.G. Malbrain, MD, PhD, ICU Director, Department Intensive Care Medicine, University Hospital Brussel (UZB), Laarbeeklaan 101, 1090 Jette, Belgium. E-mail: manu.malbrain@uzbrussel.be Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Review of massive transfusion protocols in the injured, bleeding patient Purpose of review Massive haemorrhage is a significant cause of mortality and morbidity in a variety of clinical settings, although most research has been related to trauma patients. Military studies from recent conflicts found that higher ratios of plasma to red blood cells (RBCs) were associated with increased survival in injured soldiers, and subsequent trials in civilian populations showed similar decreased mortality. Over the last decade, massive transfusion protocols (MTPs) have become an important component in the treatment of the massively bleeding patient. This review is intended to summarize the more recent findings and trends in massive transfusion. Recent findings There have been several observational studies suggesting that higher ratios of plasma to RBC and platelets to RBC are associated with improved survival but there is a paucity of randomized studies relating to specific ratios, dosages, timing, and guidance. Other studies have developed and assessed scoring systems used to initiate MTPs and specific tests used to guide MTPs. Finally, the specific blood components and adjuncts that constitute a MTP are the patient of further ongoing research. Summary The absence of a universal definition of massive bleeding or massive transfusion, heterogeneity in patients suffering from massive bleeding, and the difficulty in predicting which patients will require a massive transfusion all contribute to the difficulty of studying massive transfusion. However, there is evidence that higher plasma : RBC ratios correlate with improved survival, and that adjuncts to transfusion play a key role. Furthermore, recent validations of massive haemorrhage scoring systems should allow more consistent and appropriate triggering of massive transfusions. Correspondence to Terence O’Keeffe, Division of Trauma/Surgical Critical Care/General Surgery, Department of Surgery, Augusta University Medical Center, Augusta, Georgia, USA. Tel: +1 706 7213153; e-mail: tokeeffe@augusta.edu Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Coagulopathy in the surgical patient: trauma-induced and drug-induced coagulopathies Purpose of review Coagulopathy is the derangement of hemostasis that in surgical patients may result in excessive bleeding, clotting or no measurable effect. The purpose of this review is to provide an overview of the most current evidence and practical approach to trauma- and drug-induced coagulopathy in surgical patients. Recent findings Early identification and timely correction of coagulopathy in surgical patients with significant bleeding is paramount to prevent death and other consequences of hemorrhage. Trauma-induced coagulopathy is managed by protocols recommending fibrinogen replacement, FFP, platelets, TXA and frequent lab monitorization including viscoelastic tests. For warfarin- or DOAC-induced coagulopathy, the management follows similar principles plus drug reversal. Warfarin is diagnosed by prolonged international normalized ratio and reversed by PCC or FFP. DOACs are inconsistently diagnosed by routine coagulation tests, and reversed by a combination of TXA, PCC and specific antidotes (if available). Summary Despite different understandings of the pathophysiology, trauma- and drug-induced coagulopathies are managed following similar protocols. In most of cases of significant surgical bleeding, timely and protocolized approach to correct the coagulopathy is likely to improve patients’ outcome. Correspondence to Sandro Rizoli, MD, PhD, FRCSC, FACS, Department of Surgery, Trauma Surgery, Hamad General Hospital, PO Box 3050, Doha, Qatar. E-mail: srizoli@hamad.qa Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Acute respiratory failure: nonintubation assist methods for the acutely deteriorating patient Purpose of review Noninvasive ventilation is strongly recommended in acute hypercapnic respiratory failure, whereas high-flow nasal oxygen therapy could be an alternative in de novo respiratory failure. Recent findings High-flow nasal oxygen may improve the outcome of patients de novo respiratory failure as compared with standard oxygen. Its success within 2 h after initiation is well predicted by a ROX index (ratio of SpO2/FiO2 to respiratory rate) greater than 4.88, as failure when less than 3.85 at 12 h after initiation. However, the superiority of high-flow nasal oxygen to standard oxygen has not been confirmed in immunocompromised patients. Although noninvasive ventilation may be deleterious through barotrauma in patients with de novo respiratory failure, its use seems to be an optimal strategy for preoxygenation before intubation in preventing severe hypoxemia in most hypoxemic patients. In mild hypoxemic patient, high-flow nasal oxygen may be more efficient than bag-valve mask in preventing severe adverse events. After anesthetic induction further positive-pressure ventilation can better secure intubation procedure than absence of ventilation. Summary Despite the growing use of high-flow nasal oxygen, new studies are needed to confirm its superiority to standard oxygen in de novo respiratory failure and others causes of acute respiratory failure in place of standard oxygen. Correspondence to Jean-Pierre Frat, MD, Médecine Intensive Réanimation, CHU de Poitiers, 2 rue la Milétrie, 86021 Poitiers Cedex, France. Tel: +33 549444007; e-mail: jean-pierre.frat@chu-poitiers.fr Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Failure to rescue in the surgical patient: a review Purpose of review Evaluating patient outcomes is essential in a healthcare environment focused on quality. Mortality after surgery has been considered a useful quality metric. More important than mortality rate, failure to rescue (FTR) has emerged as a metric that is important and may be improveable. The purpose of this review is to define FTR, describe patient and hospital level factors that lead to FTR, and highlight possible solutions to this problem. Recent findings FTR is defined as a death following a complication. Depending on the patient population, FTR rates vary from less than 1% to over 40%. Numerous patient factors including frailty, congestive heart failure (CHF), renal failure, serum albumin <3.5, COPD, cirrhosis, and higher ASA class may predispose patients to FTR. Hospital factors including technology, teaching status, increased nurse-to-patient ratios, and closed ICUs may help reduce FTR. More difficult to measure variables, such as hospital culture and teamwork may also influence FTR rates. Early warning systems may allow earlier identification of the deteriorating patient. Summary FTR is a major clinical concern and efforts aimed at optimizing patient and hospital factors, culture and communication, as well as early identification of the deteriorating patient may improve FTR rate. Correspondence to Matthew E. Lissauer, MD, FACS, FCCM, Associate Professor of Surgery, Rutgers-Robert Wood Johnson Medical School, 125 Patterson Street, CAB 6300, New Brunswick, NJ 08901, USA. Tel: +1 732 235 7766; e-mail: ml1141@rwjms.rutgers.edu Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Emergency bedside ultrasound-benefits as well as caution: Part 2: Echocardiography Purpose of review Critical care echocardiography (CCE) has become an important component of general critical care ultrasonography, and a current review of its performance is presented. Recent findings Basic CCE should be performed as a goal-directed examination to better identify specific signs and to answer important clinical questions concerning acute hemodynamic concerns. It has evolved in the ICU and also in the emergency department not only for improved diagnostic capability but also as an effective part of the triage process. It remains an efficacious procedure even in patients with respiratory failure when combined with lung ultrasonography. Numerous acronyms were proposed, but in all cases, CCE responds to the same rules as fundamental echocardiography. Basic CCE requires accessible and comprehensive training for physicians and is mandatory for all intensivists. Development of pocket echo devices may increase the use of basic CCE as has miniaturization of other medical technologies. Performance should be managed by guidelines, and the CCE training program should be standardized worldwide. More trials are welcome to evaluate its impact on patient outcomes. Summary Thanks to its ability to quickly obtain a diagnostic orientation at the bedside and to implement targeted therapy, basic CCE over the past decade has become an essential tool for hemodynamic assessment of the cardiopulmonary unstable patient. Its more recent incorporation into the education of trainees in medical school and residencies/fellowships has reinforced its perceived importance in critical care management, despite the relative paucity as yet of rigorous scientific evidence demonstrating positive outcome modification from its use. Correspondence to Antoine Vieillard-Baron, Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Paré, Paris, France. Tel: +33 149095603; e-mail: antoine.vieillard-baron@aphp.fr Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Vitamin C in surgical sepsis Purpose of review The current review discusses the supplemental use of vitamin C as an adjunct in the management of sepsis and septic shock. Recent findings The antioxidant properties of vitamin C are touted to be useful in modulating the inflammatory response, decreasing vasopressor requirements, and improving resuscitation. Current resuscitation practices are focused on addressing the hemodynamic instability and ensuring adequate oxygen delivery to tissues. The conceptual framework of the use of vitamin C during a resuscitation is to modulate in a beneficial fashion the inflammatory response to sepsis while concomitantly resuscitating and treating the infection. While there is promising animal and burn-related data on improved fluid resuscitation with the use of vitamin C as an adjunct, the most recent meta-analyses of the available data fail to show a survival benefit in sepsis, and concerns regarding nephrotoxicity remain. Summary Although there are large number of animal studies, only a few small prospective and retrospective studies in humans address the use of vitamin C to treat sepsis. Further research in a controlled and randomized fashion is needed to determine if vitamin C is effective in this role. While there is a promise of ascorbate's addition to the sepsis bundle as an adjunct to resuscitation, the evidence is not conclusive. Correspondence to Gregory J. Jurkovich, Lloyd F. & Rosemargaret Donant Chair in Trauma Medicine, Department of Surgery, UC Davis Health, 2335 Stockton Blvd, North Addition Office Building, Room 6017, Sacramento, CA 95817, USA. E-mail: gjjurkovich@ucdavis.edu Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Massive pulmonary embolism: embolectomy or extracorporeal membrane oxygenation? Purpose of review To highlight updates on the use of extracorporeal membrane oxygenation (ECMO) and surgical embolectomy in the treatment of massive pulmonary embolism. Recent findings Outcomes for surgical embolectomy for massive pulmonary embolism have improved in the recent past. More contemporary therapeutic options include catheter embolectomy, which although offer less invasive means of treating this condition, need further study. The use of ECMO as either a bridge or mainstay of treatment in patients with contraindications to fibrinolysis and surgical embolectomy, or have failed initial fibrinolysis, has increased, with data suggesting improved outcomes with earlier implementation in selected patients. Summary Although surgical embolectomy continues to be the initial treatment of choice in massive pulmonary embolism with contraindications or failed fibrinolysis, the use of ECMO in these high-risk patients provides an important tool in managing this often fatal condition. Correspondence to Duane S. Pinto, MD, MPH, FACC, Division of Cardiology, Beth Israel Deaconess Medical, Center 1 Deaconess Road, Boston, MA 02115, USA. Tel: +1 617 632 7501; fax: +617 632 7460; e-mail: dpinto@bidmc.harvard.edu Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.