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The effects of an enteral nutrition feeding protocol on critically ill patients: A prospective multi-center, before-after study

This trial by Jiang and others was published online in the Journal of Critical Care during January 2020.
Purpose:  The aim of this study was to explore the effects of an enteral nutrition (EN) feeding protocol in critically ill patients.
Methods:  This was a prospective multi-center before-after study. We compared energy related and prognostic indicators between the control group (pre-implementation stage) and intervention group (post-implementation stage). The primary endpoint was the percentage of patients receiving EN within 7 days after ICU admission.
Results:  209 patients in the control group and 230 patients in the intervention group were enrolled. The implementation of the EN protocol increased the percentage of target energy reached from day 3 to day 7, and the difference between two groups reached statistical significance in day 6 (P = .01) and day 7 (P = .002). But it had no effects on proportion of patient receiving EN (P = .65) and start time of EN (P = .90). The protocol application might be associated with better hospital survival (89.1% vs 82.8%, P = .055) and reduce the incidence of EN related adverse (P = .004). There was no difference in ICU length of stay, duration of mechanical ventilation and ICU cost.
Conclusion:  The implementation of the enteral feeding protocol is associated with improved energy intake and a decreased incidence of enteral nutrition related adverse events for critically ill patients, but it had no statistically beneficial effects on reducing the hospital mortality rate.
The full text of this article is available to subscribers via this link to the journal’s homepage.  The full text of articles from issues older than sixty days is available via this link to an archive of issues of Journal of Critical Care.  A Rotherham NHS Athens password is required.  Eligible staff can register for an Athens password via this link.  Please speak to the library staff for more details.

Impact of the pre-illness lipid profile on sepsis mortality

This research by Maile et al was published online in the Journal of Critical Care during January 2020.
Purpose:  To determine if baseline lipid levels contribute to the relationship between lipid levels during sepsis and outcomes.
Materials and methods:  We conducted a retrospective cohort study at a tertiary-care academic medical center. Multi-variable logistic regression models were used to adjust for confounders. Both Systemic Inflammatory Response Syndrome (SIRS) and Sequential Organ Failure Assessment (SOFA) score-based definitions of sepsis were analyzed.
Measurements and main results:  After adjusting for patient characteristics and severity of illness, baseline values for both low density lipoprotein (LDL) cholesterol and triglycerides were associated with mortality (LDL cholesterol odds ratio [OR] 0.44, 95% confidence interval [CI] 0.23–0.84, p = .013; triglyceride OR 0.54, 95% CI 0.37–0.78, p = .001) using a SIRS based definition of sepsis. An interaction existed between these two variables, which resulted in increased mortality with higher baseline low density lipoprotein (LDL) cholesterol values for individuals with triglycerides below 208 mg/dL and the opposite direction of association above this level (interaction OR 1.48, 95% CI 1.02–2.16, p = .039). When using a SOFA score-based definition, only triglycerides remained associated with the mortality (OR 0.55, 95% CI 0.35–0.86, p = .008).
Conclusions:  Baseline lipid values, particularly triglyceride concentrations, are associated with hospital mortality in septic patients.
The full text of this article is available to subscribers via this link to the journal’s homepage.  The full text of articles from issues older than sixty days is available via this link to an archive of issues of Journal of Critical Care.  A Rotherham NHS Athens password is required.  Eligible staff can register for an Athens password via this link.  Please speak to the library staff for more details.

From a pressure-guided to a perfusion-centered resuscitation strategy in septic shock: Critical literature review and illustrative case

This research by Gazmuri and Anez de Gomez was published online in the Journal of Critical Care during January 2020.
Purpose:  To support a paradigm shift in the management of septic shock from pressure-guided to perfusion-centered, expected to improve outcome while reducing adverse effects from vasopressor therapy and aggressive fluid resuscitation.
Material and methods:  Critical review of the literature cited in support of vasopressor use to achieve a predefined mean arterial pressure (MAP) of 65 mmHg and review of pertinent clinical trials and studies enabling deeper understanding of the hemodynamic pathophysiology supportive of a perfusion-centered approach, accompanied by an illustrative case.
Results:  Review of the literature cited by the Surviving Sepsis Campaign revealed lack of controlled clinical trials supporting outcome benefits from vasopressors. Additional literature review revealed adverse effects associated with vasopressors and worsened outcome in some studies. Vasopressors increase MAP primarily by peripheral vasoconstriction and in occasions by a modest increase in cardiac output when using norepinephrine. Thus, achieving the recommended MAP of 65 mmHg using vasopressors should not be presumed indicative that organ perfusion has been restored. It may instead create a false sense of hemodynamic stability hampering shock resolution.
Conclusions:  We propose focusing the hemodynamic management of septic shock on reversing organ hypoperfusion instead of attaining a predefined MAP target as the key strategy for improving outcome.
The full text of this article is available to subscribers via this link to the journal’s homepage.  The full text of articles from issues older than sixty days is available via this link to an archive of issues of Journal of Critical Care.  A Rotherham NHS Athens password is required.  Eligible staff can register for an Athens password via this link.  Please speak to the library staff for more details.

Critical Care Reviews Newsletter 421 5th January 2020

The Critical Care Reviews Newsletter, bringing you the best critical care research and open access articles from across the medical literature over the past seven days.
“The highlights of this week’s edition are randomised controlled trials on the effect of treating parents colonized with Staphylococcus aureus on transmission to neonates in the ICU & endovascular treatment versus standard medical treatment for vertebrobasilar artery occlusion; systematic reviews and meta analyses on acute kidney injury in burn patients & safety of intravenous thrombolysis among patients taking direct oral anticoagulants; and observational studies on potentially preventable intensive care unit admissions in the united states & predicting mortality among critically ill patients with acute kidney injury treated with renal replacement therapy.”
The full text of the newsletters is available via this link.

Early High-Dose Vitamin D3 for Critically Ill, Vitamin D-Deficient Patients.

This article produced by National Heart, Lung, and Blood Institute PETAL Clinical Trials Network was first published in “The New England journal of medicine; Dec 2019; volume 381 issue 26.
Background:  Vitamin D deficiency is a common, potentially reversible contributor to morbidity and mortality among critically ill patients. The potential benefits of vitamin D supplementation in acute critical illness require further study.
Methods:  We conducted a randomized, double-blind, placebo-controlled, phase 3 trial of early vitamin D3 supplementation in critically ill, vitamin D-deficient patients who were at high risk for death. Randomization occurred within 12 hours after the decision to admit the patient to an intensive care unit. Eligible patients received a single enteral dose of 540,000 IU of vitamin D3 or matched placebo. The primary end point was 90-day all-cause, all-location mortality.
Results:  A total of 1360 patients were found to be vitamin D-deficient during point-of-care screening and underwent randomization. Of these patients, 1078 had baseline vitamin D deficiency (25-hydroxyvitamin D level, <20 ng per milliliter [50 nmol per liter]) confirmed by subsequent testing and were included in the primary analysis population. The mean day 3 level of 25-hydroxyvitamin D was 46.9±23.2 ng per milliliter (117±58 nmol per liter) in the vitamin D group and 11.4±5.6 ng per milliliter (28±14 nmol per liter) in the placebo group (difference, 35.5 ng per milliliter; 95% confidence interval [CI], 31.5 to 39.6). The 90-day mortality was 23.5% in the vitamin D group (125 of 531 patients) and 20.6% in the placebo group (109 of 528 patients) (difference, 2.9 percentage points; 95% CI, -2.1 to 7.9; P = 0.26). There were no clinically important differences between the groups with respect to secondary clinical, physiological, or safety end points. The severity of vitamin D deficiency at baseline did not affect the association between the treatment assignment and mortality.
Conclusions:  Early administration of high-dose enteral vitamin D3 did not provide an advantage over placebo with respect to 90-day mortality or other, nonfatal outcomes among critically ill, vitamin D-deficient patients. (Funded by the National Heart, Lung, and Blood Institute; VIOLET ClinicalTrials.gov number, NCT03096314.).
The printed copy of the New England Journal of Medicine is available in the Health Care Library on D Level of Rotherham Hospital.
The full text of articles from issues older than sixty days is available via this link to an archive of issues of New England Journal of Medicine A Rotherham NHS Athens password is required.  Eligible staff can register for an Athens password via this link.  Please speak to the library staff for more details.

Critical Care Reviews Newsletter 420 29th December 2019

The Critical Care Reviews Newsletter, bringing you the best critical care research and open access articles from across the medical literature over the past seven days.“The highlights of this week’s edition are a randomised controlled trial on timing of staged nonculprit artery revascularization in patients with ST-segment elevation myocardial infarction; systematic reviews and meta analyses investigating terlipressin vs norepinephrine in septic shock & ketamine sedation in mechanically ventilated patients; and an observational study on a post hoc analysis of the ADRENAL trial. There are also guidelines on central venous access & management of the child’s airway under anaesthesia; narrative reviews on neuroimaging in traumatic brain injury & the microcirculation; editorials on adjuvant vitamin C for sepsis & transcranial doppler; and commentaries on the responsibility of physicians to maintain competency & when could human challenge trials be deployed to combat emerging infectious diseases; as well as correspondence on global warming “heating up” the ICU through Candida auris infections & dynamic hyperinflation and intrinsic PEEP in ARDS patients.

The full text of the newsletters is available via this link.

Targeted Temperature Management for Cardiac Arrest with Nonshockable Rhythm.

This article by Lascarrou and colleagues was published in the New England Journal of Medicine volume 381 number 24 during December 2019
Background:  Moderate therapeutic hypothermia is currently recommended to improve neurologic outcomes in adults with persistent coma after resuscitated out-of-hospital cardiac arrest. However, the effectiveness of moderate therapeutic hypothermia in patients with nonshockable rhythms (asystole or pulseless electrical activity) is debated.
Methods:  We performed an open-label, randomized, controlled trial comparing moderate therapeutic hypothermia (33°C during the first 24 hours) with targeted normothermia (37°C) in patients with coma who had been admitted to the intensive care unit (ICU) after resuscitation from cardiac arrest with nonshockable rhythm. The primary outcome was survival with a favorable neurologic outcome, assessed on day 90 after randomization with the use of the Cerebral Performance Category (CPC) scale (which ranges from 1 to 5, with higher scores indicating greater disability). We defined a favorable neurologic outcome as a CPC score of 1 or 2. Outcome assessment was blinded. Mortality and safety were also assessed.
Results:  From January 2014 through January 2018, a total of 584 patients from 25 ICUs underwent randomization, and 581 were included in the analysis (3 patients withdrew consent). On day 90, a total of 29 of 284 patients (10.2%) in the hypothermia group were alive with a CPC score of 1 or 2, as compared with 17 of 297 (5.7%) in the normothermia group (difference, 4.5 percentage points; 95% confidence interval [CI], 0.1 to 8.9; P = 0.04). Mortality at 90 days did not differ significantly between the hypothermia group and the normothermia group (81.3% and 83.2%, respectively; difference, -1.9 percentage points; 95% CI, -8.0 to 4.3). The incidence of prespecified adverse events did not differ significantly between groups.
Conclusions:  Among patients with coma who had been resuscitated from cardiac arrest with nonshockable rhythm, moderate therapeutic hypothermia at 33°C for 24 hours led to a higher percentage of patients who survived with a favorable neurologic outcome at day 90 than was observed with targeted normothermia.
The printed copy of the New England Journal of Medicine is available in the Health Care Library on D Level of Rotherham Hospital.
The full text of articles from issues older than sixty days is available via this link to an archive of issues of New England Journal of Medicine.  A Rotherham NHS Athens password is required.  Eligible staff can register for an Athens password via this link Please speak to the library staff for more details.