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Gastroenterology Critical Care

Sort P, Navasa M, Arroyo V, et al. Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. N Engl J Med 1999;341:403-9. RCT found addition of albumin to cefotaxime vs. antibiotic alone in above population preserved renal function and reduced mortality. Study does not provide information on volume resuscitation in the antibiotic-alone group, however, making it less clear whether albumin has additional benefit beyond what could be achieved with aggressive crystalloids.

PMID: 10432325

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García-Pagán JC, Caca K, Bureau C, et al. for the Early TIPS (Transjugular Intrahepatic Portosystemic Shunt) Cooperative Study Group. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med 2010;362:2370-9. In a prospective study of 63 patients with acute variceal bleeding, TIPS placement within 72 hours led to a reduction in mortality and rebleeding rate.

PMID: 20573925

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Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013; 368:11-21. A large multi-center trial that found a hemoglobin goal of of 7 mg/dL during acute upper gastrointestinal bleed resulted in a lower risk of re-bleeding, adverse events, and a decreased hazard ratio for death at 6 weeks when compared with a 9 mg/dL target. Patients with rapid exsanguination were excluded. The mortality benefit appears greatest in patients with Child-Pugh class A or B cirrhosis.

PMID: 23281973

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Nadim MK, Durand F, Kellum JA, et al. Management of the critically ill patient with cirrhosis: A multidisciplinary perspective. J Hepatol. 2016; 64:717-35. This multi-society and multidisciplinary consensus statement promotes the emerging concept of acute on chronic liver failure (ACLF) and provides a series of graded recommendations on general and organ-specific management issues in the critically ill patient with cirrhosis. It relies heavily on expert opinion, however this reflects the complexity of the ACLF population and paucity of available data.

PMID: 26519602

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Krag M, Marker S, Perner A et al. Pantoprazole in patients at risk for gastrointestinal bleeding in the ICU. N Engl J Med. 2018; 379:2199-2208. This multicenter blinded trial randomized ~3300 ICU patients at risk for gastrointestinal bleeding to 40 mg of intravenous pantoprazole or placebo daily during the ICU stay. There was no difference in 90 day mortality. Significant bleeding was uncommon, affecting 2.5% of the PPI group and 4.2% for placebo. There was no significant difference in incidence of C. difficile infection or pneumonia.

PMID: 30354950

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