Malnutrition in critically ill patients in intensive care units

The provision of artificial nutrition for critically ill patients is of great importance as many are unable to maintain their own nutritional needs. The administration of total parenteral nutrition (TPN) and enteral nutrition (EN) has become a daily practice in intensive care units. Despite this, many patients remain undernourished or even malnourished and it is estimated that the incidence of malnutrition in intensive care patients could be as high as 50% (McCain, 1993). The reasons by which patients become or remain undernourished are multifactorial and range from physiological to iatrogenic. In order to lessen the catabolic state which results from the hypermetabolism associated with critical illness, prompt and adequate nutritional support must be delivered. It is essential that members of the multidisciplinary team caring for critically ill patients are aware of the importance of nutrition and the deleterious effects of malnutrition to achieve the best possible outcome for patients.     

Candiduria in critically ill patients admitted to intensive care medical units

BACKGROUND: The purpose of this study was to determine the incidence of candiduria in critically ill patients admitted to intensive care medical units (ICUs), to identify risk factors for candiduria and to assess the frequency distribution of different Candidaspp. SUBJECTS AND METHODS: This was a prospective cohort observational and multicenter study. A total of 1,765 patients older than 18 years of age who were admitted for at least 7 days to 73 medical-surgical ICUs of 70 Spanish hospitals were included in the study. Urine cultures were performed once a week. RESULTS. In 389 patients (22%), Candidaspp. in one or more urine samples were isolated. In the multivariate analysis, independent risk factors for candiduria included: age >65 years, female sex, length of hospital stay before ICU admission, diabetes mellitus, total parenteral nutrition, mechanical ventilation and previous use of antimicrobials. Candida albicanswas recovered in 266 cases (68.4%), followed by C. glabrata(32 cases, 8.2%) and C. tropicalis(14 cases, 36%). Previous use of antifungal agents was the only risk factor for the selection of Candidanon-albicans candiduria (OR 2.64, 95% CI 1.35-5.14, P=0.004). In-hospital mortality was 48.8% in patients with candiduria compared to 36.6% in those without candiduria ( P<0.001). Significant differences were also found for ICU mortality (38.% vs. 28.1%, P<0.001). CONCLUSIONS: Twenty-two percent of critically ill patients admitted for more than 7 days in the ICU developed candiduria. C. albicanswas the most frequent causative pathogen. Previous use of antifungals was the only risk factor for the selection of Candidanon-albicans.     

Impact of delayed admission to intensive care units on mortality of critically ill patients: a cohort study

Introduction  

When the number of patients who require intensive care is greater than the number of beds available, intensive care unit (ICU) entry flow is obstructed. This phenomenon has been associated with higher mortality rates in patients that are not admitted despite their need, and in patients that are admitted but are waiting for a bed. The purpose of this study is to evaluate if a delay in ICU admission affects mortality for critically ill patients.     

Evaluation of a dosing regimen for continuous vancomycin infusion in critically ill patients: An observational study in intensive care unit patients

Purpose

We aimed to evaluate a dosing algorithm for continuous vancomycin administration in intensive care unit patients.

Materials and Methods

This observational study was conducted in a medical intensive care unit (German university hospital; June 2012-February 2013). Following a loading dose of 20 mg per kg actual body weight, vancomycin was administered continuously (20 or 30 mg of vancomycin per kg actual body weight over 24 hours depending on renal function). The vancomycin infusion rate was adjusted to achieve a target serum vancomycin concentration of 20-30 mg/L.

Results

Vancomycin was administered for a median (interquartile range) of 7 (5-9) days. The median vancomycin dose given as an initial bolus was 1750 (1400-2000) mg. The median daily vancomycin dose ranged from 480 (180–960) mg (day 6) to 3.120 (2596-3980) mg (day 1). Altogether, the achieved median serum vancomycin concentration was 29.0 (25.2-33.2) mg/L. On treatment days 1 to 7, we observed target serum vancomycin levels (20-30 mg/L) in 48%, 39%, 33%, 26%, 43%, 57%, and 69% of patients. Supra-therapeutic serum vancomycin concentrations (> 30 mg/L) were observed in 36%, 52%, 61%, 63%, 39%, 19%, and 15% of patients on treatment days 1 to 7.

Conclusions

The evaluated vancomycin dosing regimen for continuous infusion allowed rapid achievement of sufficient vancomycin serum levels. However, we frequently observed supra-therapeutic serum vancomycin concentrations in the first days of vancomycin treatment.     

重症加强治疗病房清醒患者不良住院经历调查分析

目的 调查重症加强治疗病房(ICU)清醒危重患者住院期间心理及生理不良经历的发生情况,并分析相关诱发因素.方法 选择全国31家三级甲等医院ICU进行为期2个月的连续性调查,所有转出ICU的清醒患者均入选本次调查,于转出后2 d内由上海诺德健康咨询有限公司委派、经课题组系统培训合格的访问员按问卷要求独立对患者进行访问.结果 共计234例患者接受调查,其中163例(69.6%)发生了心理不良经历;有生理不良经历患者的比例高达97.0%,其中74.8%的患者发生了严重生理不良经历.有86.5%存在心理不良经历的患者发生了严重生理不良经历,显著高于无心理不良经历的患者(46.5%),差异有统计学意义(P<0.01).分别有65.8%和74.8%的患者抱怨对噪音及医护操作难以忍受,且此类患者心理及生理不良经历的比例均较能耐受者显著增高(P<0.05或P<0.01).多因素分析发现,急性生理学与慢性健康状况评分系统Ⅱ(APACHE Ⅱ)评分为诱发心理不良经历的独立高危因素[优势比(OR)=1.070,95%可信区间(CI)为1.020～1.130,P<0.05];年龄因素为发生生理不良经历的高危因素(OR=0.936,95%CI为0.879～0.998,P<0.05).此外,恰当的镇静能有效降低ICU清醒危重患者心理及生理不良经历的发生率.结论 ICU清醒危重患者不良住院经历发生率高,存在心理不良经历的患者更容易出现生理不良经历.疾病严重程度是诱发不良心理经历的独立危险因素,ICU环境因素(如噪音)以及医护操作与心理及生理不良经历关系密切,而恰当的ICU镇静策略是减少心理及生理不良经历的有效措施之一.     

Antithrombin III in patients admitted to intensive care units: a multicenter observational study

Introduction  

The administration of antithrombin III (ATIII) is useful in patients with congenital deficiency, but evidence for the other therapeutic indications of this drug is still uncertain. In Italy, the use of ATIII is very common in intensive care units (ICUs). For this reason we undertook an observational study to determine the pattern of use of ATIII in ICUs and to assess the outcome of patients given this treatment.     

Aerosol therapy in intensive and intermediate care units: prospective observation of 2808 critically ill patients

Purpose

Unlike in the outpatient setting, delivery of aerosols to critically ill patients may be considered complex, particularly in ventilated patients, and benefits remain to be proven. Many factors influence aerosol delivery and recommendations exist, but little is known about knowledge translation into clinical practice.

Methods

Two-week cross-sectional study to assess the prevalence of aerosol therapy in 81 intensive and intermediate care units in 22 countries. All aerosols delivered to patients breathing spontaneously, ventilated invasively or noninvasively (NIV) were recorded, and drugs, devices, ventilator settings, circuit set-up, humidification and side effects were noted.

Results

A total of 9714 aerosols were administered to 678 of the 2808 admitted patients (24 %, CI₉₅ 22–26 %), whereas only 271 patients (10 %) were taking inhaled medication before admission. There were large variations among centers, from 0 to 57 %. Among intubated patients 22 % (n = 262) received aerosols, and 50 % (n = 149) of patients undergoing NIV, predominantly (75 %) inbetween NIV sessions. Bronchodilators (n = 7960) and corticosteroids (n = 1233) were the most frequently delivered drugs (88 % overall), predominantly but not exclusively (49 %) administered to patients with chronic airway disease. An anti-infectious drug was aerosolized 509 times (5 % of all aerosols) for nosocomial infections. Jet-nebulizers were the most frequently used device (56 %), followed by metered dose inhalers (23 %). Only 106 (<1 %) mild side effects were observed, despite frequent suboptimal set-ups such as an external gas supply of jet nebulizers for intubated patients.

Conclusions

Aerosol therapy concerns every fourth critically ill patient and one-fifth of ventilated patients.

     

Survival of critically ill patients hospitalized in and out of intensive care units under paucity of intensive care unit beds

OBJECTIVE: The demand for intensive care beds far exceeds their availability in many European countries. Consequently, many critically ill patients occupy hospital beds outside intensive care units, throughout the hospital. The outcome of patients who fit intensive care unit admission criteria but are hospitalized in regular wards needs to be assessed for policy implications. The object was to screen entire hospital patient populations for critically ill patients and compare their 30-day survival in and out of the intensive care unit. DESIGN: Screening teams visited every hospital ward on four selected days in five acute care Israeli hospitals. The teams listed all patients fitting a priori developed study criteria. One-month data for each patient were abstracted from the medical records. SETTING: Five acute care Israeli hospitals. PATIENTS: All patients fitting a priori developed study criteria. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Survival in and out of the intensive care unit was compared for screened patients from the day a patient first met study criteria. Cox multivariate models were constructed to adjust survival comparisons for various confounding factors. The effect of intensive care unit vs. other departments was estimated separately for the first 3 days after deterioration and for the remaining follow-up time. Results showed that 5.5% of adult hospitalized patients were critically ill (736 of 13,415). Of these, 27% were admitted to intensive care units, 24% to specialized care units, and 49% to regular departments. Admission to an intensive care unit was associated with better survival during the first 3 days of deterioration, after we adjusted for age and severity of illness (p =.018). There was no additional survival advantage for intensive care unit patients (p =.9) during the remaining follow-up time. CONCLUSIONS: The early survival advantage in the intensive care unit suggests a window of critical opportunity for these patients. Under economic constraints and dearth of intensive care unit beds, increasing the turnover of patients in the intensive care unit, thus exposing more needy patients to the early benefit of treatment in the intensive care unit, may be advantageous.     

Resuscitation fluid use in critically ill adults: an international cross-sectional study in 391 intensive care units

Introduction  

Recent evidence suggests that choice of fluid used for resuscitation may influence mortality in critically ill patients.     

Early intervention on the outcomes in critically ill cancer patients admitted to intensive care units

Purpose

To determine whether earlier intervention was associated with decreased mortality in critically ill cancer patients admitted to an intensive care unit (ICU).

Methods

A retrospective observational study was performed of 199 critically ill cancer patients admitted to the ICU from the general ward between January 2010 and December 2010. A logistic regression model was used to adjust for potential confounding factors in the association between time to intervention and in-hospital mortality.

Results

In-hospital mortality was 52?%, with a median Simplified Acute Physiology Score 3 (SAPS 3) of 80 [interquartile range (IQR) 67–93], and a median Sequential Organ Failure Assessment (SOFA) score of 8 (IQR 5–11). Median time from physiological derangement to intervention (time to intervention) prior to ICU admission was 1.5 (IQR 0.6–4.3)?h. Median time to intervention was significantly shorter in survivors than in non-survivors (0.9 vs. 3.0?h; p?p?2/FiO₂ ratio. Even after adjusting for potential confounding factors, time to intervention was still significantly associated with hospital mortality (adjusted odds ratio 1.445, 95?% confidence interval 1.217–1.717).

Conclusions

Early intervention before ICU admission was independently associated with decreased in-hospital mortality in critically ill cancer patients admitted to the ICU.     

Gastrointestinal failure score in critically ill patients: a prospective observational study

Introduction

There are no universally accepted diagnostic criteria for gastrointestinal failure in critically ill patients. In the present study we tested whether the occurrence of food intolerance (FI) and intra-abdominal hypertension (IAH), combined in a 5-grade scoring system for assessment of gastrointestinal function (the Gastrointestinal Failure [GIF] score), predicts mortality. The prognostic value of the GIF score alone and in combination with the Sequential Organ Failure Assessment (SOFA) score is evaluated, and the incidence and outcome of gastrointestinal failure is described relative to the GIF score.

Methods

A total of 264 subsequently hospitalized patients, who were mechanically ventilated on admission and stayed in the intensive care unit (ICU) for longer than 24 hours, were prospectively studied. GIF score was documented daily as follows: 0 = normal gastrointestinal function; 1 = enteral feeding with under 50% of calculated needs or no feeding 3 days after abdominal surgery; 2 = FI or IAH; 3 = FI and IAH; and 4 = abdominal compartment syndrome (ACS). Admission parameters and mean GIF and SOFA scores for the first 3 days were used to predict ICU outcome.

Results

FI developed in 58.3%, IAH in 27.3%, and both together in 22.7% of patients. The mean GIF score for the first 3 days in the ICU was identified as an independent risk factor for mortality (odds ratio = 3.02, 95% confidence interval = 1.63 to 5.59; P < 0.001). The GIF score integrated into the SOFA score allowed better prediction of ICU mortality than did the SOFA score alone, and was an independent predictor of mortality (odds ratio = 1.49, 95% confidence interval = 1.28 to 1.74; P < 0.001). The development of gastrointestinal failure (FI plus IAH) was associated with significantly higher ICU and 90-day mortality.

Conclusion

The GIF score is useful for classifying information on the gastrointestinal system. The mean GIF score during the first 3 days in the ICU had high prognostic value for ICU mortality. Development of gastrointestinal failure is associated with significantly impaired outcome.     

Erythropoietin response in critically ill mechanically ventilated patients: a prospective observational study

Introduction

Anemia is a common problem in critically ill patients. The etiology of anemia of critical illness is often determined to be multifactorial in the clinical setting, but the pathophysiology remains to be elucidated. Erythropoietin (EPO) is an endogenous glycoprotein hormone that serves as the primary stimulus for erythropoiesis. Recent evidence has demonstrated a blunted EPO response as a factor contributing to anemia of critical illness in specific subsets of patients. Critically ill patients requiring mechanical ventilation who exhibit anemia have not been the subject of previous studies. Our goal was to evaluate the erythropoietic response to anemia in the critically ill mechanically ventilated patient.

Methods

A prospective observational study was undertaken in the medical intensive care unit of a tertiary care, military hospital. Twenty patients admitted to the medical intensive care unit requiring mechanical ventilation for at least 72 hours were enrolled as study patients. EPO levels and complete blood count were measured 72 hours after admission and initiation of mechanical ventilation. Admission clinical and demographic data were recorded, and patients were followed for the duration of mechanical ventilation. Twenty patients diagnosed with iron deficiency anemia in the outpatient setting were enrolled as a control population. Control patients had baseline complete blood count and iron panel recorded by primary care physicians. EPO levels were measured at the time of enrollment in conjunction with complete blood count.

Results

The mean EPO level for the control population was 60.9 mU/ml. The mean EPO level in the mechanically ventilated patient group was 28.7 mU/ml, which was significantly less than in the control group (P = 0.035). The mean hemoglobin value was not significantly different between groups (10.6 g/dl in mechanically ventilated patients versus 10.2 g/dl in control patients; P > 0.05).

Conclusion

Mechanically ventilated patients demonstrate a blunted EPO response to anemia. Further study of therapies directed at treating anemia of critical illness and evaluating its potential impact on mechanical ventilation outcomes and mortality is warranted.

     

Accidental catheter removal in critically ill patients: a prospective and observational study

Introduction  

The importance of accidental catheter removal (ACR) lies in the complications caused by the removal itself and by catheter reinsertion. To the best of our knowledge, no studies have analyzed accidental removal of various types of catheters in the intensive care unit (ICU). The objective of the present study was to analyze the incidence of ACR for all types of catheters in the ICU.     

Pleural effusion in critically ill patients and intensive care setting

Pleural effusion usually causes a diagnostic dilemma with a long list of differential diagnoses. Many studies found a high prevalence of pleural effusions in critically ill and mechanically ventilated patients, with a wide range of variable prevalence rates of up to 50%-60% in some studies. This review emphasizes the importance of pleural effusion diagnosis and management in patients admitted to the intensive care unit(ICU). The original disease that caused pleural effusion can be the exact caus...     

Development of demographics and outcome of very old critically ill patients admitted to intensive care units

Purpose  

To evaluate the development of demographics and outcome of very old (>80 years) critically ill patients admitted to intensive care units.     

移动ICU的构建和应用效果

目的 提高重症患者院内转运的安全性和可行性,加强对危重患者转运的管理,确保危重患者的安全.方法 针对重症患者转运中存在的问题,在2012年构建并实施按监护室标准配备的移动ICU,以专业化转运人员、监护和生命支持设备、二级救护站点、转运流程和预案为要素,严格进行质量控制,完成患者院内安全转运.结果 共成功转运患者214例次,一次转运成功211例次.本组中有3例机械通气患者在转运起始阶段脉搏血氧饱和度下降至90％以下,即刻返回ICU,病情稳定后再次转运成功.本组无人工气道移位和意外死亡等情况发生.结论 移动ICU转运延续了监护室环境和危重病管理水平,可降低危重患者转运不良事件的发生,提高转运的安全性.