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Acute-on-chronic liver failure (AoCLF) represents a newly defined entity in patients with liver disease leading to multiple organ failures and increased mortality. To date, no universally accepted definition exists, and different academic societies developed guidelines on the early diagnosis and classification of AoCLF. Recently published trials focused on factors associated with a poor outcome and on the development of severity scores aimed to identify patients who may benefit for advanced monitoring and treatment. No specific therapies are demonstrated to improve survival, and liver transplantation (LT) remains the only treatment associated with improved outcome. Our review focuses on current evidence for early diagnosis and prognostication of disease in patients with AoCLF, as well of criteria for intensive care unit admission, indication, and futility markers of LT, as well as bridging therapy and optimal timing of surgery.

The explosion of the new coronavirus (SARS-CoV-2) pandemic has brought the role of the angiotensin converting enzyme 2 (ACE2) back into the scientific limelight. Since SARS-CoV-2 must bind the ACE2 for entering the host cells in humans, its expression and body localization are critical to track the potential target organ of this infection and to outline disease progression and clinical outcomes. Here, we mapped the physiological body distribution, expression, and activities of ACE2 and discussed its potential correlations and mutal interactions with the disparate symptoms present in SARS-CoV-2 patients at the level of different organs. We highlighted that despite during SARS-CoV-2 infection ACE2-expressing organs may become direct targets, leading to severe pathological manifestations, and subsequent multiple organ failures, the exact mechanism and the potential interactions through which ACE2 acts in these organs is still heavily debated. Further scientific efforts, also considering a personalized approach aimed to consider specific patient differences in the mutual interactions ACE2-SARS-CoV-2 and the long-term health effects associated with COVID-19 are currently mandatory.

Uncontrolled bleeding can lead to many complications that might cause multiple organ failures and even death. Of all the hemostatic agents used, chitosan has been reported to show better hemostatic potential. It acts through one mechanism involved in hemostasis that is plug formation by adhering to the injured site. Hence our focus is to enhance the hemostatic potential of chitosan (Ch) hydrogel by incorporating nano whitlockite (nWH: Ca

Background & Aims Multiple organ failures (OFs) are common in patients with cirrhosis, but the independent effect of the number or type of OFs on liver transplantation (LT) outcomes is not well defined. Method United Network for Organ Sharing data were analyzed from 2002 to 2016 for all adults listed for LT who received an LT within 30 days after listing. We estimated post-LT survival stratified by number and type of pre-transplant OFs before and after adjusting for confounding variables. Results During the study period, 4,714 (4.1%) patients died and 19,375 (16.6%) patients were transplanted within 30 days of listing. One or more OF were more common in those who were transplanted (57.4%) compared to those without LT (9.5%). The probability of staying alive more than 30 days on the waiting list without LT decreased with increasing number of OFs; while 90% were alive without OF, only 20% were alive with two OFs, and 2–8% with three or more OFs. The interval between listing and transplantation decreased with an increase in OFs, and the median time to transplant after listing was only 4–5 days with three or more OFs. Although the risk of post-LT mortality increased with increasing number of OFs, the 90-day patient survival was 90% and one-year survival was 81% in the presence of 5–6 OFs. The number of OFs was an independent predictor of survival, but the maximum difference in one-year graft or patient survival between those without OF and those with 5–6 OFs was only 9%. Additionally, the type of OF had minimal impact on outcomes. Conclusions Liver transplantation is feasible with excellent outcomes, even in the presence of five or six OFs. Lay summary Multiple organ failures, ranging from 1–6, are common in hospitalized patients with cirrhosis. The survival without liver transplant is dismal in the presence of three or more organ failures. Small retrospective studies have shown that liver transplant is feasible with good outcomes even in the presence of multiple organ failures. In this study, using a large national dataset, we show that survival chances for more than 30 days in those with three or more organ failures are less than 8%. However, if a liver transplant is performed quickly, the survival chances are very high with one-year survival ranging from 84% with three organ failures to 81% with 5–6 organ failures.

The spread of a new coronavirus infection worldwide since the end of 2019 has becomes a pandemic Thrombotic complications are the leading cause of death in this disease After entering the human body, the virus starts a cascade of reactions leading to the development of a cytokine storm, activation of all parts of the hemostasis and complement systems and other changes that result in disturbances in the circulation system with the development of multiple organ failures Numerous studies have shown that a predictor of a severe course of COVID-19 is a sharp increase of D-dimer concentration in the blood and rise of some other markers of hemostasis activation Based on the pathogenesis, the developed schemes for the prevention and treatment of COVID-19 severe complications include low molecular weight heparins (LMWH) which are also recommended for an outpatient COVID-19 patient The prescription of low molecular weight heparin, the duration of their use and doses should be decided on the basis of a risk assessment of factors for each individual patient in combination with laboratory monitoring Распространение новой коронавирусной инфекции по всему миру с конца 2019 г превратилось в пандемию Тромботические осложнения являются ведущей причиной смерти при этом заболевании После попадания в организм человека вирус запускает каскад реакций, приводящих к развитию цитокинового «шторма», активации всех звеньев системы гемостаза и комплемента, другим изменениям, приводящим к нарушениям в системе кровообращения с развитием полиорганных нарушений Многочисленные исследования показали, что предиктором тяжелого течения заболевания является резкое повышение концентрации D-димера в крови и некоторых других маркеров активации гемостаза Исходя из патогенеза, разработанные схемы профилактики и лечения тяжелых осложнений COVID-19 включают низкомолекулярные гепарины, которые также рекомендуют для применения в амбулаторных условиях Назначение низкомолекулярных гепаринов, длительность их применения и дозы должны определяться на основе оценки факторов риска для каждого отдельного пациента в сочетании с лабораторным мониторингом

Critically ill patients often suffer from multiple organ failures involving lung, kidney, liver, or brain. Genomic, proteomic, and metabolomic approaches highlight common injury mechanisms leading to acute organ failure. This underlines the need to focus on therapeutic strategies affecting multiple injury pathways. The use of adult stem cells such as mesenchymal stem or stromal cells (MSC) may represent a promising new therapeutic approach as increasing evidence shows that MSC can exert protective effects following injury through the release of promitotic, antiapoptotic, antiinflammatory, and immunomodulatory soluble factors. Furthermore, they can mitigate metabolomic and oxidative stress imbalance. In this work, the authors review the biological capabilities of MSC and the results of clinical trials using MSC as therapy in acute organ injuries. Although preliminary results are encouraging, more studies concerning safety and efficacy of MSC therapy are needed to determine their optimal clinical use. (Anesthesiology 2014; 121:1099-121)

A 39-year-old woman is admitted with clinical, biochemical and imaging features suggestive of acute pancreatitis. Conservative and guideline based management failed to improve her condition. Repeate the imaging utilizing contrast revealed the progression of extra-pancreatic signs in the absence of pancreatic necrosis, the absence of intra-abdominal fluid collections, but enhancing omental and peritoneal deposits and obstructive pancreatitis. A biopsy and histopathological evaluation of the omentum revealed rare anaplastic large cell lymphoma causing obstructive pancreatitis. In patients who present with pancreatitis not responding to conventional treatment and with an atypical disease course, the diagnostic possibility of rare causes of pancreatitis such as obstructive/infiltrative pathology must be thought of.

© 2016 IEEE. Critical ICU events like acute hypotension and septic shock are dangerous complications, leading to multiple organ failures and eventual death. Previously, pattern mining algorithms have been employed for extracting interesting rules in various clinical domains. However, the extracted rules are directly investigated by clinicians for diagnosing a disease. Towards this purpose, there is a need to develop advanced prediction models which integrate dynamic patterns to learn a patient's physiological condition. In this study, a sequential contrast patterns-based classification framework is presented for detecting critical patient events, like hypotension and septic shock. Initially, a set of sequential patterns are obtained by using a contrast mining algorithm. Later, these patterns undergo post-processing, for conversion to two novel representations-(1) frequency-based feature space and (2) ordered sequences of patterns, which conserve positional information of a pattern in a time series sequence. Each of these representations are automatically used for developing classification models using SVM and HMM methods. Our results on hypotension and septic shock datasets from a large scale ICU database demonstrate better predictive capabilities, when sequential patterns are used as features.

The annual incidence of acute kidney injury (AKI) has been increasing as the population ages. Despite advances in critical care and dialysis technology, the mortality remains unacceptably high in patients with AKI during the past few decades. Renal replacement therapy (RRT) is performed to treat patients with severe AKI and multiple organ failures, as well as to remove fluid in patients with fluid overload including those with acute heart failure and lung edema in the intensive care unit (ICU). The mortality in patients with AKI requiring RRT is higher than 50 %. RRT strategies in patients with AKI depend on various conditions. However, there is little consensus on when to start and stop RRT, its optimal dose, and the choice of different RRT modalities (intermittent versus (vs.) continuous) in patients with AKI. Patients with AKI in the ICU are preferentially treated with continuous rather than intermittent RRT (IRRT), usually because of hemodynamic stability and steady of solute clearance. At present, the type and dose of RRT are dependent on the experience of the attending clinicians, including intensivists and nephrologists.

Phenol burns can result in multiple organ failure. This is a case report of acute severe phenol dermal burn after accidental splash of 94% phenol on 35-year-old patient's body who was brought to hospital after 90 min of exposure. Decontamination was done with high-density water and glycerol. Early complications in form of metabolic acidosis and acute renal failure required hemodialysis. Extensive protein denaturation was managed with IV albumin and high protein diet. Patient also developed pleural effusion and acute respiratory distress syndrome, but these were successfully managed by intercostal drain tube insertion and noninvasive ventilation. The patient survived after multiple organ failures and widespread burns despite the fact that it has been observed that outcome of phenol burns with >60(2) inches of skin affected or two or more organs failure involving renal system is nearly fatal.

Mucopolysaccharidosis type VI (MPS VI) is a progressive, autosomal, recessive lysosomal disorder. This disorder, due to a deficiency in N-acetylgalactosamine-4-sulfatase (ASB), results in an accumulation of glycosaminoglycan (GAG), causing multiple organ failures. In this study, monochorionic biamniotic twins with the severe form of MPS VI underwent enzyme replacement therapy (ERT) with weekly infusions of recombinant human ASB (galsulfase) at 1 mg/kg. After 9 years of ERT, a comprehensive clinical examination was performed. Several types of biochemical, immunological, and genetic investigations were also conducted. Both twins showed the typical symptoms and signs of MPS VI at baseline, including short stature, progressive dysmorphic facial features, and dysostosis multiplex. Twin 2 presented stronger multisystemic involvement, with marked musculoskeletal, neurological, and odontological components. She also developed an ischemic spinal cord lesion after surgery, which is the first case described in the literature in Maroteaux–Lamy syndrome. However, the extent of disease was found to be equally stabilized in the two sisters, concretely the cardiac and respiratory functions and body length. The early diagnosis and treatment of MPS VI are critical for an optimal clinical outcome, and further evidence for the new treatment strategies is needed.

There is a need for reliable continuous monitoring of abdominal organ oxygen saturation (SpO2). Splanchnic ischaemia may ultimately lead to cellular hypoxia and necrosis and may well contribute to the development of multiple organ failures and increased mortality. A new reflectance electro-optical photoplethysmographic (PPG) probe and signal processing system were developed. PPG signals from abdominal organs (bowel, liver, and kidney) and the finger were obtained from 12 anaesthetised patients. The amplitudes of the abdominal organ PPGs were, on average, approximately the same as those obtained simultaneously from the finger. These observations suggest that pulse oximetry may be a valid monitoring technique for abdominal organs such as the bowel liver and kidney.

急性腎不全は多臓器不全の一分症として高率に生じる臓器不全の一つであり,死亡率は依然として高い.原因疾患として敗血症が多く,病態には種々のmediatorと組織酸素代謝の失調が関与する.対策としては,十分な輸液を行い,腎毒性のある薬剤を避けるとともに,循環への影響が少なく,体液の正常化と溶質除去の他に,多臓器不全共通の発症因子であるmediator除去を目的に持続的血液濾過透析を用いることが推奨される.

Clinical evidence indicates that intensive insulin treatment prevents the incidence of multiple organ failures in surgical operation and severe trauma, but the mechanisms involved remain elusive. This study was designed to test the hypothesis that insulin may exert anti-inflammatory and antioxidative effects and thus alleviate cardiac dysfunction after trauma.Prospective, randomized experimental study.Animal research laboratory.Sprague Dawley rats.Anesthetized rats were subjected to 200 revolutions at a rate of 35 rpm in Noble-Collip drum to induce a nonlethal mechanical trauma and were randomized to receive vehicle, insulin, and insulin + wortmannin treatments. An in vitro study was performed on cultured cardiomyocytes subjected to sham-traumatic serum (SS), traumatic serum (TS), SS + tumor necrosis factor (TNF)-α, SS + H2O2, TS + neutralizing anti-TNF-α antibody, or TS + tempol treatments.Immediate cardiac dysfunction occurred 0.5 hr after trauma without significant cardiomyocyte necrosis and apoptosis, while serum TNF-α and cardiac reactive oxygen species (ROS) production was increased. Importantly, incubation of cardiomyocytes with TS or SS + TNF-α significantly increased ROS generation together with dampened cardiomyocyte contractility and Ca transient, all of which were rescued by TNF-α antibody. Administration of insulin inhibited TNF-α and ROS overproduction and alleviated cardiac dysfunction 2 hours after trauma. Scavenging ROS with tempol also attenuated cardiac dysfunction after trauma, whereas insulin combined with tempol failed to further improve cardiac functional recovery compared with insulin treatment alone. Moreover, the aforementioned anti-TNF-α, antioxidative, and cardioprotective effects afforded by insulin were almost abolished by the phosphatidylinositol 3-kinase inhibitor wortmannin.These results demonstrate for the first time that mechanical trauma induces a significant increase in TNF-α and ROS production, resulting in immediate cardiac dysfunction. Early posttrauma insulin treatment alleviates cardiac dysfunction by inhibiting TNF-α-mediated ROS production via a phosphatidylinositol 3-kinase/Akt-dependent mechanism.

The assessment of the level of hydration in the intravascular fluid compartment in acute renal failure (ARF) and multiple organ failure (MOF) is of an utmost importance. However, the data on monitoring of blood volume in these diseases and especially during haemodialysis treatment are lacking. This article summarizing the experience of monitoring of blood volume in chronic haemodialysis suggests that the application of such monitoring will contribute to better results in haemodialysis treatment of ARF and MOF.

SUMMARY The key to the differential diagnosis of these related conditions is knowledge of the natural history of each disease process; an awareness of how this usually translates in each instance into clinical and laboratory parameters; an appreciation for the wide spectrum of findings for each of these conditions, which are more aptly considered disease syndromes rather than single diseases; and the good fortune to encounter the patient early enough or midway in the course of her disease, prior to terminal stages when all subtle differences among disease syndromes almost disappear in a blur of grossly abnormal physiology and multiple organ failures.

Introduction: Postoperative course of cardiac surgery patients in presence of liver dysfunction is associated with a lot of complications like excessive bleeding, coagulopathy, hepatic decompensation, multiple organ failure, infections which account for increased mortality and morbidity among this subset of patients. Method: In this study we evaluate early postoperative outcome of elective cardiac surgery in patients with hepatitis B infection. We studied 21 patients with hepatitis B infection who underwent open heart surgery done at department of cardiothoracic surgery, S.M.S Medical college, Jaipur, Rajasthan, India. All preoperative, operative and postoperative data was collected and analysed. Results: Out of 21 patient 13 were operated for coronary artery bypass grafting of these 7 were done offpump and 6 were done onpump. Out of remaining 8 patients 5 were mitral valve replacement for mitral valve disease and 3 were double valve replacement. Out of 21 patients 9 were re-explored for bleeding. Of the total patients operated 5 patients died, of which 1 succumb to renal failure, 3 died due to excessive bleeding and coagulopathy and 1 died due to delayed recovery following cerebral haemorrhage. 6 patients developed sternal wound infection and 2 out of these required sternal rewiring and debridement. Mean hospital stay was around 18 days with mortality of 23.8% and mobidity of around 28.6%. Conclusion: In the study group we found that there is considerable increase in mortality and morbidity among patients with hepatitis B infection that underwent open heart surgery.

Successful management of incidents with chemical warfare agents strongly depends on the speed of medical help and the ability of helpers to react properly. Though the general principles of clinical toxicology, such as decontamination, stabilization, patient evaluation and symptomatic treatment are similar for many toxicants, chemical warfare agents deserve special attention because of their very high inhalative and cutaneous toxicity, rapid onset of the disease and multiple organ failures. This article describes the medical management of mass casualties with blister agents, nerve agents and blood agents from the viewpoint of a clinical toxicologist. Characteristic diagnostic signs, decontamination procedures and therapeutic schemes for these agents are described. Treatment options are discussed. The importance of planning (e.g. antidote availability) and preparedness is emphasized.

Sepsis results from complex interactions between infecting microorganisms and host responses, often leading to multiple organ failures and death. Over the years, its treatment has been standardized in early goal-oriented therapies, which may benefit from circulating biomarkers for early risk stratification. We aimed to evaluate the prognostic value of presepsin (sCD14-ST), a novel marker of bacterial infection.

Septic shock remains a major cause of morbidity and mortality among children, mainly due to acute haemodynamic compromise and multiple organ failures. In the last decade, international guidelines for the management of septic shock, as well as clinical practice parameters for hemodynamic support of pediatric patients, have been published. Early recognition and aggressive therapy of septic shock, by means of abundant fluid resuscitation, use of catecholamines and other adjuvant drugs, are widely considered of pivotal importance to improve the short and long-term outcome of these patients. The aim of this paper is to summarize the modern approach to septic shock in children, particularly in its very initial phase, when pediatric healthcare providers may be required to intervene in the pre-intensive care unit setting or just on admission in the pediatric intensive care unit.

Pseudo-obstruction of the colon is an acute abdominal problem that can occur from a variety of causes and multiple organ failures. It is characterized by massive colonic dilatation and a clinical picture suggestive of mechanical large-intestinal obstruction, without any organic obstruction. Decompression should be cautiously attempted with proctoscopy and, possibly, colonoscopy; if these fail, then surgical decompression, usually be a cecostomy, is indicated.

To evaluate the results of a multidisciplinary intensive care unit (ICU) 228 patients (group I) have been prospectively studied and compared to a control group of 98 patients (group II) treated only in an intermediate unit. The health status (HS) was estimated A : good health, B : chronic and minor health problem with limited activity, C : chronic and major health problem with very decreased activity, D : institutionalized patient. Three months before ICU, then 1, 3 and 12 months after discharge, the HS was measured by physical examination or phone interview. Patients of group I had multiple organ failures and a level of therapy 4 times higher than in group II. Immediate survival rate was 67 per cent and 49 per cent after one year. Twenty per cent of surviving patients were still hospitalized three months after discharge. One year later 33 per cent of the 228 entering patients had a A or B health status level. All these results are significantly different from those of the control group.