Traditional weight-based vancomycin dosing is inadequate in critically ill trauma patients

Purpose  

Our aim was to evaluate our institution’s compliance with weight-based vancomycin dosing recommendations for pneumonia in critically ill injured patients and to assess the success rate in achieving therapeutic serum vancomycin levels. Additionally, we sought to assess the incidence of vancomycin-induced nephrotoxicity.     

Hypovitaminosis D and insulin resistance in peritoneal dialysis patients

Aim  

An association between hypovitaminosis D and insulin resistance has been highlighted. Effects of vitamin D are not only mediated via the vitamin D receptors by active vitamin D metabolites, but 25(OH)D₃ also acts through VDR-independent pathways directly. It was reported that acute and chronic intravenous 1,25-dihydroxycholecalciferol therapy corrects insulin resistance in dialysis patients. There are no studies in patients on dialysis which evaluated relationship between 25(OH)D levels and insulin resistance. The aim of this study was to evaluate relationship between serum 25 (OH) D levels and insulin resistance in nondiabetic patients on peritoneal dialysis (PD).     

Nutrition therapy for critically ill and injured patients

Background

Nutrition support has undergone significant advances in recent decades, revolutionizing the care of critically ill and injured patients. However, providing adequate and optimal nutrition therapy for such patients is very challenging: it requires careful attention and an understanding of the biology of the individual patient’s disease or injury process, including insight into the consequent changes in nutrients needed.

Objective

The objective of this article is to review the current principles and practices of providing nutrition therapy for critically ill and injured patients.

Methods

Review of the literature and evidence-based guidelines.

Results

The evidence demonstrates the need to understand the biology of nutrition therapy for critically ill and injured patients, tailored to their individual disease or injury, age, and comorbidities.

Conclusion

Nutrition therapy for critically ill and injured patients has become an important part of their overall care. No longer should we consider nutrition for critically ill and injured patients just as “support” but, rather, as “therapy”, because it is, indeed, a key therapeutic modality.     

Assessing the utility of ultrasound-guided vascular access placement with longer catheters in critically ill pediatric patients

Background

Critically ill pediatric patients can have difficulty with establishing and maintaining stable vascular access. A long-dwelling peripheral intravenous catheter placement decreases the need for additional vascular interventions.

Aim

The study sought to compare longevity, catheter-associated complications, and the need for additional vascular interventions when using ultrasound-guided longer peripheral intravenous catheters comparing to a traditional approach using standard-sized peripheral intravenous catheters in pediatric critically ill patients with difficult vascular access.

Methods

This single-center retrospective cohort study included children 0–18 years of age with difficult vascular access admitted to the pediatric intensive care unit between 01/01/2018–06/01/2021.

Results

One hundred and eighty seven placements were included in the study, with 99 ultrasound-guided long intravenous catheters placed and 88 traditionally placed standard-sized intravenous catheters. In the univariate analysis, patients in the traditional approach were at a higher risk of intravenous failure compared to those in the ultrasound-guided approach (HR = 2.20, 95% CI [1.45–3.34], p = .001), with median intravenous survival times of 108 and 219 h, respectively. Adjusting for age, patients in the traditional approach remained at higher risk of intravenous failure (HR = 1.99, 95% CI: [1.28–3.08], p = .002). Adjusting for hospital length of stay, patients in the ultrasound-guided approach were less likely to have additional peripheral intravenous access placed during hospitalization (OR = 0.39, 95% CI [0.18–0.85] p = .017).

Conclusion

In critically ill pediatric patients with difficult vascular access, ultrasound-guided long peripheral intravenous catheters provide an alternative to traditional approach standard-sized intravenous catheters with improved longevity, lower failure rates, and reduced need for additional vascular interventions.     

Hypoxic hepatitis in critically ill patients: incidence, etiology and risk factors for mortality

Purpose  

Hypoxic hepatitis may be induced by hemodynamic instability or arterial hypoxemia in critically ill patients. We investigated the incidence, etiology, association with systemic ischemic injury and risk factors for mortality in this population.     

YKL-40 is Elevated in Morbidly Obese Patients and Declines After Weight Loss

Background  

Patients suffering from morbid obesity (MO) have an increased cardiovascular morbidity and mortality. This increased cardiovascular burden is believed to be caused by a sub-inflammatory state through an increased secretion of monocyte chemoattractant protein-1 (MCP-1) by the adipose tissue, resulting in insulin resistance (IR) and type 2 diabetes mellitus (T2DM). YKL-40, which is elevated in inflammatory processes in T2DM and IR and in ruptured plaques, might as well be involved in the increased cardiovascular burden of MO patients. The present study aims to study the level of YKL-40 in MO patients before and after weight loss as well as to investigate the relationship between YKL-40, IR, MCP-1, and obesity.     

New-onset atrial fibrillation in critically ill adult patients—an SSAI clinical practice guideline

Background

Acute or new-onset atrial fibrillation (NOAF) is the most common cardiac arrhythmia in critically ill adult patients, and observational data suggests that NOAF is associated to adverse outcomes.

Methods

We prepared this guideline according to the Grading of Recommendations Assessment, Development and Evaluation methodology. We posed the following clinical questions: (1) what is the better first-line pharmacological agent for the treatment of NOAF in critically ill adult patients?, (2) should we use direct current (DC) cardioversion in critically ill adult patients with NOAF and hemodynamic instability caused by atrial fibrillation?, (3) should we use anticoagulant therapy in critically ill adult patients with NOAF?, and (4) should critically ill adult patients with NOAF receive follow-up after discharge from hospital? We assessed patient-important outcomes, including mortality, thromboembolic events, and adverse events. Patients and relatives were part of the guideline panel.

Results

The quantity and quality of evidence on the management of NOAF in critically ill adults was very limited, and we did not identify any relevant direct or indirect evidence from randomized clinical trials for the prespecified PICO questions. We were able to propose one weak recommendation against routine use of therapeutic dose anticoagulant therapy, and one best practice statement for routine follow-up by a cardiologist after hospital discharge. We were not able to propose any recommendations on the better first-line pharmacological agent or whether to use DC cardioversion in critically ill patients with hemodynamic instability induced by NOAF. An electronic version of this guideline in layered and interactive format is available in MAGIC: https://app.magicapp.org/#/guideline/7197 .

Conclusions

The body of evidence on the management of NOAF in critically ill adults is very limited and not informed by direct evidence from randomized clinical trials. Practice variation appears considerable.     

Association of insulin resistance with arterial stiffness in nondiabetic peritoneal dialysis patients

Background  

Insulin resistance is a risk factor for cardiovascular morbidity and mortality in the general and end-stage renal disease populations. In this study, we investigated the association between insulin resistance and arterial stiffness in nondiabetic peritoneal dialysis (PD) patients.     

Short- and long-term outcomes following percutaneous cholecystostomy for acute cholecystitis in high-risk patients

Background  

Percutaneous cholecystostomy is a less invasive method to treat acute cholecystitis in patients who are critically ill or have serious medical comorbidities precluding the use of general anesthesia. It remains controversial whether interval cholecystectomy is warranted. The objectives of the study were to determine the success rate and complications of percutaneous cholecystostomy and the proportion of patients without recurrent attacks in whom interval cholecystectomy was not needed.     

Perioperative exercise for chronic liver injury patients with hepatocellular carcinoma undergoing hepatectomy

Background

The aim of this study was to examine the outcomes of exercise therapy in patients with hepatocellular carcinoma who underwent hepatectomy.

Methods

Fifty-one patients with hepatocellular carcinoma were randomized to diet therapy alone (n = 25) or to exercise in addition to diet therapy (n = 26). Exercise at the anaerobic threshold of each patient was started 1 month preoperatively, resumed from 1 week postoperatively, and continued for 6 months.

Results

Whole body mass and fat mass in the exercise group compared with the diet group were significantly decreased at 6 months postoperatively. Fasting serum insulin and the homeostasis model assessment score were also significantly decreased. At 6 months, anaerobic threshold and peak oxygen consumption were significantly increased, while serum insulin and insulin resistance were significantly improved in a high-frequency exercise subgroup compared with a low-frequency group.

Conclusions

Perioperative exercise therapy for patients with hepatocellular carcinoma with liver dysfunction may improve insulin resistance associated with hepatic impairment and suggests a benefit to the early resumption of daily exercise after hepatectomy.     

Correlation of calculated indices of insulin resistance (QUICKI and HOMA) with the euglycaemic hyperinsulinaemic clamp technique for evaluating insulin resistance in critically ill patients

BACKGROUND AND OBJECTIVE: Insulin resistance is frequently observed in critical illness. It can be quantified by the expensive and time-consuming euglycaemic hyperinsulinaemic clamp technique (M-value) and calculated indices of insulin resistance (Quantitative Insulin Sensitivity Check Index; QUICKI and Homeostasis Model Assessment; HOMA) with lower costs and efforts. We performed an observational study to assess the reliability of QUICKI and HOMA to evaluate insulin resistance in critically ill patients compared with the current gold standard method, the euglycaemic hyperinsulinaemic clamp technique. METHODS: Insulin resistance was measured in 30 critically ill medical patients by the euglycaemic hyperinsulinaemic clamp technique (M-value) as well as calculated using QUICKI and HOMA. Correlations between the M-values as well as QUICKI and HOMA were assessed by means of the Pearson's correlation coefficient. RESULTS: M-value, QUICKI and HOMA indicated insulin resistance in all 30 patients. However, both indices QUICKI and HOMA did not correlate with the M-values in our patients (r2 = 0.008 and 0.0005, respectively). A significant negative correlation was found between the M-value and the severity of illness assessed by the APACHE (Acute Physiology and Chronic Health Evaluation) III score (r2 = 0.16; P < 0.05). In contrast, neither HOMA nor QUICKI correlated with the APACHE III score (r2 = 0.034 and 0.033, respectively). CONCLUSIONS: Although QUICKI and HOMA indicated insulin resistance in the critically ill medical patients, both indices did not correlate with the M-value. Therefore, the euglycaemic hyperinsulinaemic clamp technique remains the gold standard for estimating insulin resistance in critically ill patients.     

Respiratory distress in patients with central airway obstruction

Introduction  

Patients with respiratory distress due to central airway obstruction (Trachea, carina or main bronchi) are critically ill with impending suffocation. This obstruction is caused by a variety of benign and malignant causes that might be intraluminal, extra luminal or combined.     

Perioperative Selective Decontamination of the Digestive Tract (SDD) in Elective Colorectal Surgery

Background  

Selective decontamination of the digestive tract (SDD) decreases morbidity and mortality in critically ill patients and morbidity in patients undergoing esophageal resection. This study analyzes the effect of perioperative SDD in patients undergoing elective colorectal surgery on postoperative infections and anastomotic leakage.     

Which variables are associated with blood glucose levels outside the target range in surgical critically ill patients? A retrospective observational study

Background  

The aim of the present study is to determine the variables affecting blood glucose concentrations outside the target range of 80 and 150 mg/dl in critically ill surgical patients.     

Propofol and Intralipid cause creaming of serum from critically ill patients

The aim of this in-vitro study was to investigate the incidence of propofol agglutination with serum from critically ill patients. Serum (400 μl) from 58 critically ill patients and 30 healthy volunteers was incubated with 10 μl of either propofol, Intralipid 10% or Intralipid 20%. Control incubations contained serum only. At 24 h, the serum was examined macroscopically and microscopically for agglutination. Agglutination was seen with Intralipid 20% in serum from all critically ill patients and 13.3% of volunteers. Serum from 91.4% of critically ill patients was agglutinated with Intralipid 10% and only 3.3% of the healthy volunteers. In comparison, propofol produced agglutination in 74.1% of critically ill patients and in none of the serum from healthy volunteers (p < 0.05 propofol versus Intralipid 10%, p < 0.0001 propofol versus Intralipid 20%). No correlation was seen between agglutination and age, sex, APACHE II score or plasma concentration of acute phase proteins. However, agglutination of propofol and Intralipid 10% was more frequent (p < 0.001) in serum from patients with pulmonary disease, than in patients with normal lungs. The clinical implications of these in-vitro findings are unclear and need further investigation.     

Effects of intra-abdominal pressure on liver function assessed with the LiMON in critically ill patients

Background

Intra-abdominal pressure (IAP) and intra-abdominal hypertension (IAH) are associated with significant morbidity and mortality in critically ill patients. Our aim was to assess the effects of IAH on liver function using the noninvasive liver function monitoring system LiMON and to assess the prognostic value of IAP in critically ill patients.

Methods

We conducted a retrospective analysis of critically ill patients who were treated in the intensive care unit (ICU). The IAP and indocyanine green plasma disappearance rate (ICG-PDR) measurements were made within 24 hours after admission to the ICU and repeated 12 hours later. Intra-abdominal pressure was measured via a Foley bladder catheter, and ICG elimination tests were conducted concurrently using the LiMON.

Results

We included 30 critically ill patients (17 women and 13 men aged 28–89 yr) in our analysis. Statistical analysis showed that the baseline IAP values were significantly higher among nonsurvivors than survivors (19.38 [standard deviation; SD 2.08] v. 13.07 [SD 0.99]). The twelfth-hour IAP values were higher than baseline measurements among nonsurvivors (21.50 [SD 1.96]) and lower than baseline measurements among survivors (11.71 [SD 1.54]); the difference between groups was significant (p < 0.001). The baseline ICG-PDR values were significantly lower among nonsurvivors than survivors (10.86 [SD 3.35] v. 24.51 [SD 6.78]), and the twelfth-hour ICG-PDR values were decreased in all groups; the difference between groups was significant (p < 0.001).

Conclusion

Our results suggest that measurement of ICG-PDR with the LiMON is a good predictor of the effects of IAP on liver function and, thus, can be recommended for the evaluation of critically ill patients.     

Visfatin and endogenous secretory receptor for advanced glycation end-products in diabetic type 2 and non-diabetic patients undergoing intermittent hemodialysis

Background/aims  

To examine plasma levels of visfatin and endogenous secretory receptor for advanced glycation end-products (esRAGE) in diabetic and non-diabetic patients treated with intermittent hemodialysis (IHD), and to explore the possible associations between them, insulin resistance evaluated by homeostasis model assessment for insulin resistance (HOMA-IR), as well as selected biochemical and anthropometric parameters.     

Intensity of care and withdrawal of life-sustaining therapies in severe traumatic brain injury patients: a post-hoc analysis of a multicentre retrospective cohort study

Purpose

The intensity of care provided to critically ill patients has been shown to be associated with mortality. In patients with traumatic brain injury (TBI), specialized neurocritical care is often required, but whether it affects clinically significant outcomes is unknown. We aimed to determine the association of the intensity of care on mortality and the incidence of withdrawal of life-sustaining therapies in critically ill patients with severe TBI.

Methods

We conducted a post hoc analysis of a multicentre retrospective cohort study of critically ill adult patients with severe TBI. We defined the intensity of care as a daily cumulative sum of interventions during the intensive care unit stay. Our outcome measures were all-cause hospital mortality and the incidence of withdrawal of life-sustaining therapies.

Results

Seven hundred sixteen severe TBI patients were included in our study. Most were male (77%) with a mean (standard deviation) age of 42 (20.5) yr and a median [interquartile range] Glasgow Coma Scale score of 3 [3-6]. Our results showed an association between the intensity of care and mortality (hazard ratio [HR], 0.69; 95% confidence interval [CI], 0.63 to 0.74) and the incidence of withdrawal of life-sustaining therapy (HR, 0.73; 95% CI, 0.67 to 0.79).

Conclusion

In general, more intense care was associated with fewer deaths and a lower incidence of withdrawal of life-sustaining therapies in critically ill patients with severe TBI.

     

Continuous or intermittent renal replacement for treatment of severe acute kidney injury in critically ill patients

Background  

In critically ill patients with acute kidney injury (AKI), it remains controversial whether the type of renal replacement therapy (RRT) is associated with improved clinical outcomes.     

A case report of a new pulmonary embolism occurring in a patient receiving continuous infusion of recombinant activated protein C

Background  

There are no guidelines governing the concomitant use of recombinant human activated protein C (rhAPC) and deep venous thrombosis/pulmonary embolism (DVT/PE) prophylaxis in critically ill patients. It is unknown if rhAPC provides any protection against DVT/PE in this population of patients.