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Background Critically ill patients commonly experience skeletal muscle wasting that may predict clinical outcome. Ultrasound is a noninvasive method that can measure muscle quadriceps muscle layer thickness (QMLT) and subsequently lean body mass (LBM) at the bedside. However, currently the reliability of these measurements are unknown. The objectives of this study were to evaluate the intra- and interreliability of measuring QMLT using bedside ultrasound. Methods Ultrasound measurements of QMLT were conducted at 7 centers on healthy volunteers. Trainers were instructed to perform measurements twice on each patient, and then a second trainee repeated the measurement. Intrarater reliability measured how consistently the same person measured the subject according to intraclass correlation (ICC). Interrater reliability measured how consistently trainer and trainee agreed when measuring the same subject according to the ICC. Results We collected 42 pairs of within operator measurements with an ICC of .98 and 78 pairs of trainer-to-trainee measurements with an ICC of .95. There were no statistically significant differences between the trainer and trainee results (trainer and trainee mean = −0.028 cm, 95% CI = −0.067 to −0.011, P = .1607). Conclusions Excellent intra- and interrater reliability for ultrasound measurements of QMLT in healthy volunteers was observed when performed by a range of providers with no prior ultrasound experience, including dietitians, nurses, physicians, and research assistants. This technique shows promise as a method to evaluate LBM status in ICU or hospital settings and as a method to assess the effects of nutrition and exercise-based interventions on muscle wasting.

Objectives: To develop evidence-based recommendations for clinicians caring for adults with acute or acute on chronic liver failure in the ICU. Design: The guideline panel comprised 29 members with expertise in aspects of care of the critically ill patient with liver failure and/or methodology. The Society of Critical Care Medicine standard operating procedures manual and conflict-of-interest policy were followed throughout. Teleconferences and electronic-based discussion among the panel, as well as within subgroups, served as an integral part of the guideline development. Setting: The panel was divided into nine subgroups: cardiovascular, hematology, pulmonary, renal, endocrine and nutrition, gastrointestinal, infection, perioperative, and neurology. Interventions: We developed and selected population, intervention, comparison, and outcomes questions according to importance to patients and practicing clinicians. For each population, intervention, comparison, and outcomes question, we conducted a systematic review aiming to identify the best available evidence, statistically summarized the evidence whenever applicable, and assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence to decision framework to facilitate recommendations formulation as strong or conditional. We followed strict criteria to formulate best practice statements. Measurements and Main Results: In this article, we report 29 recommendations (from 30 population, intervention, comparison, and outcomes questions) on the management acute or acute on chronic liver failure in the ICU, related to five groups (cardiovascular, hematology, pulmonary, renal, and endocrine). Overall, six were strong recommendations, 19 were conditional recommendations, four were best-practice statements, and in two instances, the panel did not issue a recommendation due to insufficient evidence. Conclusions: Multidisciplinary international experts were able to formulate evidence-based recommendations for the management acute or acute on chronic liver failure in the ICU, acknowledging that most recommendations were based on low-quality indirect evidence.

Summary Background Spontaneous bacterial peritonitis (SBP)‐associated septic shock carries significant mortality in cirrhosis. Aim To determine whether practice‐related aspects of antimicrobial therapy contribute to high mortality. Methods Retrospective cohort study of all (n = 126) cirrhotics with spontaneous bacterial peritonitis (neutrophil count >250 or positive ascitic culture)‐associated septic shock (1996–2011) from an international, multicenter database. Appropriate antimicrobial therapy implied either in vitro activity against a subsequently isolated pathogen (culture positive) or empiric management consistent with broadly accepted norms (culture negative). Results Overall hospital mortality was 81.8%. Comparing survivors (n = 23) with non‐survivors (n = 103), survivors had lower Acute Physiology and Chronic Health Evaluation (APACHEII) (mean ± s.d.; 22 ± 7 vs. 32 ± 8) and model for end‐stage liver disease (MELD) (24 ± 9 vs. 34 ± 11) scores and serum lactate on admission (4.9 ± 3.1 vs. 8.9  ± 5.3), P < 0.001 for all. Survivors were less likely to receive inappropriate initial antimicrobial therapy (0% vs. 25%, P = 0.013) and received appropriate antimicrobial therapy earlier [median 1.8 (1.1–5.2) vs. 9.5 (3.9–14.3) h, P < 0.001]. After adjusting for covariates, APACHEII [OR, odds ratio 1.45 (1.04–2.02) per 1 unit increment, P = 0.03], lactate [OR 2.34 (1.04–5.29) per unit increment, P = 0.04] and time delay to appropriate antimicrobials [OR 1.86 (1.10–3.14) per hour increment, P = 0.02] were significantly associated with increased mortality. Conclusions Cirrhotic patients with septic shock secondary to spontaneous bacterial peritonitis have high mortality (>80%). Each hour of delay in appropriate antimicrobial therapy was associated with a 1.86 times increased hospital mortality. Admission APACHEII and serum lactate also significantly impacted hospital mortality. Earlier initiation of appropriate antimicrobial therapy could substantially improve outcome.

Intraoperative transfusion of packed red blood cells, pretransplantation renal replacement therapy and APACHE II score are predictors for the development of delirium in intensive care unit patients post-OLT and are associated with increased hospital lengths of stay and mortality.