The number of patients developing liver failure; acute on chronic liver failure and acute liver failure continues to increase, along with the demand for donor livers for transplantation. As such there is a clinical need to develop effective extracorporeal devices to support patients with acute liver failure or acute-on-chronic liver failure to allow time for hepatocyte regeneration, and so avoiding the need for liver transplantation, or to bridge the patient to liver transplantation, and also potentially to provide symptomatic relief for patients with cirrhosis not suitable for transplantation. Currently devices can be divided into those designed to remove toxins, including plasma exchange, high permeability dialyzers and adsorption columns or membranes, coupled with replacement of plasma proteins; albumin dialysis systems; and bioartificial devices which may provide some of the biological functions of the liver. In the future we expect combinations of these devices in clinical practice, due to the developments in bioartificial scaffolds.
FUSIC haemodynamics (HD) – the latest Focused Ultrasound in Intensive Care (FUSIC) module created by the Intensive Care Society (ICS) – describes a complete haemodynamic assessment with ultrasound based on ten key clinical questions: 1. Is stroke volume abnormal? 2. Is stroke volume responsive to fluid, vasopressors or inotropes? 3. Is the aorta abnormal? 4. Is the aortic valve, mitral valve or tricuspid valve severely abnormal? 5. Is there systolic anterior motion of the mitral valve? 6. Is there a regional wall motion abnormality? 7. Are there features of raised left atrial pressure? 8. Are there features of right ventricular impairment or raised pulmonary artery pressure? 9. Are there features of tamponade? 10. Is there venous congestion? FUSIC HD is the first system of its kind to interrogate major cardiac, arterial and venous structures to direct time-critical interventions in acutely unwell patients. This article explains the rationale for this accreditation, outlines the training pathway and summarises the ten clinical questions. Further details are included in an online supplementary appendix.
The decision to administer thrombolysis in submassive pulmonary embolism is undertaken based on risk stratification to prevent further cardiorespiratory deterioration. Although right ventricular dysfunction has been used to risk stratify haemodynamically stable patients with acute pulmonary embolism, there is still much controversy in the use of thrombolysis for its treatment. The European Society of Cardiology guidelines suggest thrombolysis should be reserved for rescue reperfusion. However, we present a unique case of submassive pulmonary embolism in which transthoracic echocardiography visualised dynamic left ventricular outflow tract obstruction secondary to right ventricular dilatation, which led to the decision to instigate thrombolysis therapy. A 68-year-old man presented with submassive pulmonary embolism with evidence of right ventricular dysfunction but was haemodynamically stable. He was initially commenced on anticoagulation but echocardiography revealed significant right ventricular dilatation and left ventricular outflow tract obstruction, signifying a high risk of impending cardiac arrest. After deliberation, full-dose thrombolysis was administered. Subsequently the patient's symptoms and haemodynamics improved significantly and repeat echocardiography demonstrated that the right ventricular and left ventricular size and function had returned to normal. We suggest echocardiography is used to assess right heart, left heart and outflow dynamics to individualise thrombolysis therapy in patients with submassive pulmonary embolism.
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