A prospective randomised trial of probiotics in critically ill patients

BACKGROUND AND AIMS: Probiotics exert a beneficial effect on the host through modulation of gastrointestinal microflora. The aim of this study was to investigate the effect of the probiotic Lactobacillus plantarum 299v on gut barrier function and the systemic inflammatory response in critically ill patients. SUBJECTS AND METHODS: One hundred and three critically ill patients were randomised to receive an oral preparation containing L. plantarum 299v (ProViva) in addition to conventional therapy (treatment group, n = 52) or conventional therapy alone (control group, n = 51). Serial outcome measures included gastric colonisation, intestinal permeability (lactulose/rhamnose dual-sugar probe technique), endotoxin exposure (IgM EndoCAb), C-reactive protein and Interleukin 6 levels. RESULTS: L. plantarum had no identifiable effect on gastric colonisation, intestinal permeability, endotoxin exposure or serum CRP levels. There were no differences between the groups in terms of septic morbidity or mortality. On day 15 serum IL-6 levels were significantly lower in the treatment group compared to controls. CONCLUSIONS: The enteral administration of L. plantarum 299v to critically ill patients was associated with a late attenuation of the systemic inflammatory response. This was not accompanied by any significant changes in the intestinal microflora, intestinal permeability, endotoxin exposure, septic morbidity or mortality.     

The association between obesity and pressure ulcer development in critically ill patients: A prospective cohort study

BackgroundPressure ulcers (PUs) are one of the leading potentially preventable adverse events in the hospital. Critically ill patients are at risk for the development of PUs. The primary aim of the study was to investigate the relation of PUs and obesity in critically ill ICU patients.MethodsA single center prospective cohort study was conducted on adult patients with obesity (defined as a body mass index BMI ≥ 30 kg/m²) and patients without obesity (BMI 18?25 kg/m²) admitted to the intensive care unit between May 2013 and July 2017 with an ICU length of stay of at least 3 days without pre-existing PUs at admission.Results851 of 1205 patients (70.6%) had a normal BMI and 354 (29.4%) had a BMI ≥ 30 kg/m² and were considered obese. Overall, 157 patients (13.0%) developed PUs; 112/851 (13.2%) of patients without obesity and 45/354 (12.7%) of patients with obesity (p = 0.907). There was no difference in the severity (p = 0.609) and PU location (p = 0.261). Mean days to PU development was 11.1; 11.7 days for patients without obesity and 9.5 days for patients with obesity (p = 0.270). Mean days to PU recovery was 13.2, which was 14.1 days for patients without obesity and 10.8 days for patients with obesity (p = 0.215). A multivariate logistic regression model showed no significant correlation between the occurrence of PUs in the ICU and obesity (OR 0.875 with 95% CI 0.528–1.448, p = 0.594). Subgroup analysis showed that patients with morbid obesity (BMI ≥ 40 kg/m²) developed PUs earlier during ICU admission when compared to patients without obesity (p = 0.004).ConclusionOur study demonstrates that obesity is not an independent risk factor for the development of PUs in the ICU. However, patients with morbid obesity might develop PUs earlier compared to patients without obesity.     

Comparison of gastrointestinal tolerance to two enteral feeding protocols in critically ill patients: a prospective, randomized controlled trial

BACKGROUND: The purpose of this study was to compare gastrointestinal tolerance to two enteral feeding protocols in critically ill patients. METHODS: A prospective, randomized controlled trial, that involved 96 consecutive patients expected to stay in the intensive care unit for > or =3 days and who had no contraindications to enteral feeding. The patients were randomized to either the current protocol (group I; gastric residual volume threshold, 150 mL, optional prokinetic) or proposed feeding protocol (group II; gastric residual volume threshold 250 mL, mandatory prokinetic). Gastrointestinal intolerance was recorded as episodes of high gastric residual volume, emesis, or diarrhea. The time to reach the goal rate of feeding and the percentage of nutritional requirements received during the study period were also recorded. RESULTS: Nineteen of 36 patients (19/36 = 0.53) in group I had one or more episodes of high gastric residual volume, compared with 10 of 44 patients (10/44 = 0.23) in group II (p < .005). There was no statistical difference between the two protocols with regards to emesis, diarrhea, or the total episodes of intolerance. The patients in group II reached their goal rates on average in 15 hours and received 76% of their nutritional requirements, compared with 22 hours and 70% in group I; however, these differences were not statistically significant. CONCLUSIONS: The incidence of enteral feeding intolerance was reduced by using a gastric residual volume of 250 mL along with the mandatory use of prokinetics. The study showed a trend of improved enteral nutrition provision and reduced the time to reach the goal rate in group II. These improvements support the adoption of the proposed feeding protocol for critically ill patients.     

危重患者留置导管管理及感染的预防

目的 考察使用管道观察表预防有多管道危重患者发生管道感染的效果.方法 对2008年6月-2011年3月109例置入多种管道危重患者,应用管道观察表,实施多种特殊管道护理,及时进行检查与维护,预防医院管道感染.结果 109例危重多管道患者在使用特殊管道观察表后,对要定期更换的特殊管道时间一目了然,无1例因护理不到位而并发管道感染.结论 应用特殊管道观察表能加强危重患者多管道的管理,预防管道感染的发生.     

Use of a mixture of medium-chain triglycerides and longchain triglycerides versus long-chain triglycerides in critically ill surgical patients: a randomized prospective double-blind study

Twenty critically-ill surgical patients who needed total parenteral nutrition were randomly enrolled in a double-blind study comparing two intravenous fat emulsions: one containing a mixture of 50% medium-chain triglycerides and 50% long-chain triglycerides and another containing 100% longchain triglycerides. The purpose of this study was to investigate metabolic and biochemical differences between both emulsions with special reference to liver enzymes. After a baseline period of 24 h with only glucose and NaCl infusion, the lipid emulsion was added continuously during 24 h over 5 days. The parenteral nutrition was administered in mixture bags containing amino-acids, glucose and lipids together. Two-thirds of the non-protein calories were administered as glucose 40% and one third as either long-chain triglycerides or a mixture of medium-chain triglycerides and long-chain triglycerides. The total amount of non-protein calories received was the measured energy expenditure during the baseline period plus 10% and was fixed during the study. Plasma substrate concentrations, energy expenditure, and nitrogen balance were determined and arterial blood samples were taken. No toxic effects or complications attributable to one of the two emulsions were observed. There was no significant difference in energy expenditure, nitrogen balance, liver function tests, carnitine, transferrin, pre-albumin, albumin, cholesterol, triglycerides and free fatty acids. The only parameter that showed a different pattern of reaction between the two emulsions was serum bilirubin concentration. In this study no evidence of any advantageous effect of a mixture of medium-chain triglycerides and long-chain triglycerides was seen.     

Optimal protein and energy nutrition decreases mortality in mechanically ventilated, critically ill patients: a prospective observational cohort study

Background: Optimal nutrition for patients in the intensive care unit has been proposed to be the provision of energy as determined by indirect calorimetry and the provision of protein of at least 1.2 g/kg. Methods: Prospective observational cohort study in a mixed medical‐surgical intensive care unit in an academic hospital. In total, 886 consecutive mechanically ventilated patients were included. Nutrition was guided by indirect calorimetry and protein provision of at least 1.2 g/kg. Cumulative intakes were calculated for the period of mechanical ventilation. Cox regression was used to analyze the effect of protein + energy target achieved or energy target achieved versus neither target achieved on 28‐day mortality, with adjustments for sex, age, body mass index, Acute Physiology and Chronic Health Evaluation II, diagnosis, and hyperglycemic index. Results: Patients' mean age was 63 ± 16 years; body mass index, 26 ± 6; and Acute Physiology and Chronic Health Evaluation II, 23 ± 8. For neither target, energy target, and protein + energy target, energy intake was 75% ± 15%, 96% ± 5%, and 99% ± 5% of target, and protein intake was 72% ± 20%, 89% ± 10%, and 112% ± 12% of target, respectively. Hazard ratios (95% confidence interval) for energy target and protein + energy target were 0.83 (0.67–1.01) and 0.47 (0.31–0.73) for 28‐day mortality. Conclusions: Optimal nutritional therapy in mechanically ventilated, critically ill patients, defined as protein and energy targets reached, is associated with a decrease in 28‐day mortality by 50%, whereas only reaching energy targets is not associated with a reduction in mortality.     

酸性氧化电位水对危重患者置管感染的预防效果

目的研究酸性氧化电位水对危重患者置管感染的预防作用,为临床置管感染的预防提供依据。方法选择2013年1月-2015年6月住院患者1 708例,按随机数表法将其分为研究组和对照组,每组各854例,对照组患者使用生理盐水和聚维酮碘对经口气管置管、留置导尿管及中心静脉置管进行消毒,每天消毒3次,对于出现感染的患者适当增加干预次数;研究组使用酸性氧化电位水对经口气管置管、留置导尿管及中心静脉置管进行消毒,每天消毒2次;观察并记录干预后两组患者的感染率及消毒前后平均菌落数目,结果数据采用SPSSl6.0软件进行统计分析。结果患者总感染率研究组为6.0%、对照组患者为28.1%,两组比较差异有统计学意义(P0.05);两组患者干预前平均菌落数相比较差异无统计学意义,消毒后研究组患者平均菌落数为16CFU/cm2、杀灭率为80.0%;干预10min后平均菌落数为2CFU/cm2、杀灭率为97.5%,与对照组相比较,干预后研究组平均菌落数明显较少,差异有统计学意义(P0.05)。结论对于危重患者置管感染的预防与控制中,使用酸性氧化电位水的消毒作用明显。     

外科重症患者中心静脉导管相关感染微生物 分布情况分析

摘要:目的　分析该院外科重症患者中心静脉导管相关性感染微生物的分布情况,为指导临床合理用药提供依据。方法　分析该院普通外科ICU2010年8月-2014年2月收治的242例行中心静脉置管的例患者为研究对象,计算感染的总发生率、比较不同穿刺部位的感染发生率。将送检样本直接接种于血平板,并进行细菌分离鉴定及药敏试验。结果　242例患者中,有38例患者发生感染,占15.7%。其股静脉穿刺发生感染率最高,80例行股静脉穿刺的患者中,23例发生感染,感染率为28.8%;锁骨下静脉穿刺感染发生率最低,83例行锁骨下静脉穿刺患者中,4例发生感染,发生率为4.8%。38例患者一共分离得到细菌和真菌43株。其中革兰阳性菌19株,革兰阴性菌20株,真菌4株。革兰阳性菌株主要为金黄色葡萄球菌,革兰阴性菌株主要为铜绿假单胞菌以及肺炎克雷伯杆菌。金黄色葡萄球菌对于万古霉素之外的多种抗生素严重耐药,而革兰阴性菌对于碳青霉烯类抗生素以及β-内酰胺酶抑制剂敏感性有较高的敏感性。结论　外科重症患者中心静脉导管相关感染发生率比较高,病原菌的耐药性也不容乐观,在临床上要注意无菌操作以及结合药敏试验结果合理应用抗生素,以防止耐药性的进一步发展。     

A randomized trial of endoscopic and fluoroscopic placement of postpyloric feeding tubes in critically ill patients

BACKGROUND: Early postpyloric feeding is considered the accepted method of nutrition support in critically ill patients. Endoscopic and fluoroscopic techniques are associated with the highest percentage of successful placement. The purpose of this study was to compare endoscopic vs fluoroscopic placement of postpyloric feeding tubes in critically ill patients. METHODS: This is a randomized prospective clinical trial. Forty-three patients were randomized to receive feeding tubes by endoscopic or fluoroscopic technique. All procedures were performed at the bedside in the critical care unit. A soft small-bore nonweighted feeding tube was used in all cases. Successful placement was confirmed by either an abdominal x-ray for endoscopic technique or a fluoroscopic radiograph for fluoroscopic technique. RESULTS: Postpyloric feeding tubes were successfully placed in 41 of 43 patients (95%). The success rate using endoscopic technique was 96% (25 of 26), whereas the rate using fluoroscopy was 94% (16 of 17). The average time of successful placement was 15.2 +/- 2.9 (mean +/- SEM) minutes for endoscopic placement and 16.2 +/- 3.2 minutes for fluoroscopic placement, which was not statistically significant (p > .05). CONCLUSIONS: Endoscopic and fluoroscopic placement of postpyloric feeding tubes can safely and accurately be performed at the bedside in critically ill patients. Our results showed no significant difference in the success rate or time of placement between endoscopic vs fluoroscopic placement of postpyloric feeding tubes.     

Insulin therapy in critically ill patients

PURPOSE OF REVIEW: The recent publication of the results of an aggressive approach to the treatment of hyperglycaemia in critically ill patients, and a rekindling of interest in the use of an infusion of glucose insulin and potassium as adjunctive therapy in a diverse group of patients with cardiovascular disease, warrants a review of the multiple effects of insulin and a review of laboratory and clinical studies. RECENT FINDINGS: The use of an aggressive protocol to maintain normoglycaemia in critically ill patients has been demonstrated to be a beneficial technique in the critical care setting. Implementation of the protocol outside of a research setting appears to be feasible. Recent studies on the use of insulin in addition to glucose and potassium in patients with diverse cardiovascular diseases have also demonstrated positive results. SUMMARY: This review will summarize some of the putative beneficial effects of insulin as a pharmacological agent, and review recent clinical data. Although the relative benefits of normoglycaemia in the critical care setting and the beneficial effects of insulin are difficult to differentiate, a substantial overlap exists. The extent to which these converging therapies (aggressive normoglycaemia and insulin pharmacotherapy) will be applicable to diverse clinical settings has yet to be determined.     

Muscle function in critically ill patients

Endotoxemia and inflammation (cytokines) lead to an acute decrease of the muscle resting membrane potential, loss of the sodium-potassium gradient and to an increase in cytosolic Ca(2+) in critically ill intensive care unit patients. As a consequence, muscle (and nerve) contractility is reduced. As a consequence also, amino acid gradients are reduced, proteolysis is increased, the mitochondrial density is reduced to levels as low as 10% of normal within 2-3 days and cellular substrate metabolism is impaired. The author of this paper proposes that treatment modalities in clinical nutrition should primarily aim at improving muscle function and restoring muscle membrane potential and that these variables should be used as the primary outcome variables of clinical trials. Attempts to modify these measurements such that they can be used routinely in the ICU setting are ongoing in our group. Muscle protein and substrate metabolism can only be normalized when these primary variables have successfully been restored. The use of muscle relaxants may lead to a functional denervation of the muscle, to changes in the molecular structure of the myofibrils and may postpone a successfull recovery. Learning objectives: Causes of muscle weakness and loss of contractility in ICU patients; Relation between loss of contractility and impairments in muscle metabolism; Muscle function as an endpoint variable for clinical nutrition interventions.