The role of nutritional support in the physical and functional recovery of critically ill patients

The lack of benefit from randomised controlled trials has resulted in significant controversy regarding the role of nutrition during critical illness in terms of long-term recovery and outcome | Critical Care

Although methodological caveats with a failure to adequately appreciate biological mechanisms may explain these disappointing results, it must be acknowledged that nutritional support during early critical illness, when considered alone, may have limited long-term functional impact.

This narrative review focuses specifically on recent clinical trials and evaluates the impact of nutrition during critical illness on long-term physical and functional recovery.

Specific focus on the trial design and methodological limitations has been considered in detail. Limitations include delivery of caloric and protein targets, patient heterogeneity, short duration of intervention, inappropriate clinical outcomes and a disregard for baseline nutritional status and nutritional intake in the post-ICU period.

With survivorship at the forefront of critical care research, it is imperative that nutrition studies carefully consider biological mechanisms and trial design because these factors can strongly influence outcomes, in particular long-term physical and functional outcome. Failure to do so may lead to inconclusive clinical trials and consequent rejection of the potentially beneficial effects of nutrition interventions during critical illness.

Full reference: Bear, D.E. et al. (2017) The role of nutritional support in the physical and functional recovery of critically ill patients: a narrative review. Critical Care. Vol. 21 (no. 226)

Current issue of Critical Care Reviews Newsletter 298 27th August 2017

The Critical Care Reviews Newsletter brings the best critical care research and open access articles from across the medical literature from the last week.  The highlights of this week’s edition are the GRAIL trial, investigating ganciclovir in CMV-seropositive critically ill patients; several new circulatory guidelines from the European Society of Cardiology; and a fantastic series of papers from Annals of Translational Medicine, marking the 50th anniversary of the landmark description of ARDS by Ashbaugh and colleagues.  The full newsletter can be accessed via this link.

September 2017 Issue of “Intensive Care Medicine” Volume 43 Number 9

To see Intensive Care Medicine’s September issue’s contents page follow this link.  This issue focuses on the current research agenda and priorities within Intensive Care.  Examples of articles include: “The intensive care medicine agenda on acute kidney injury”, “The intensive care medicine clinical research agenda in paediatrics” and “Intensive care medicine research agenda on invasive fungal infection in critically ill patients”.

 

intensive-care-medicine

 

 
To read the full text of any of these articles via the journal’s homepage requires a personal subscription to “Intensive Care Medicine”.  Individual articles can be ordered from the Rotherham NHS Foundation Trust Library and Knowledge Service.  Registered members of the library can make article requests online via this link.

 

The full text of articles from issues older than one year ago is available via this link to an archive of issues of Intensive Care 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.

Management of multidrug-resistant Pseudomonas aeruginosa in the intensive care unit: state of the art

This research by Maraolo and colleagues was published in the “Expert review of anti-infective therapy” August 2017 edition.

Introduction:  Pseudomonas aeruginosa (PA) is one of the most important causes of healthcare-related infections among Gram-negative bacteria. The best therapeutic approach is controversial, especially for multidrug-resistant (MDR) and extensively drug-resistant (XDR) strains as well as in the setting of most severe patients, such as in the intensive care unit (ICU).

Areas covered: This article addresses several points. First, the main microbiological aspects of PA, focusing on its wide array of resistance mechanisms. Second, risk factors and the worse outcome linked to MDR-PA infection. Third, the pharmacological peculiarity of ICU patients, that makes the choice of a proper antimicrobial therapy difficult. Eventually, the current therapeutic options against MDR-PA are reviewed, taking into account the main variables that drive antimicrobial optimization in critically ill patients. Literature search was carried out using Pubmed and Web of Science.

Expert commentary: Methodologically rigorous studies are urgently needed to clarify crucial aspects of the treatment against MDR-PA, namely monotherapy versus combination therapy in empiric and targeted settings. In the meanwhile, useful options are represented by newly approved drugs, such as ceftolozane/tazobactam and ceftazidime/avibactam. In critically ill patients, at least as empirical approach, a combination therapy is a prudent choice when a MDR-PA strain is suspected.

 

The full paper can be accessed by subscribers to the “Expert Review of Anti-infective Therapy” via this link.  Some articles may be available freely without a password.  Library members can order individual articles via the Rotherham NHS Foundation Trust Library and Knowledge Service using the article requests online via this link.

Innovative haematological parameters for early diagnosis of sepsis in adult patients admitted in intensive care unit

This article by Buoro et al was published in the August issue of “Journal of Clinical Pathology”.

Aims:  This study was aimed to investigate the role of erythrocyte, platelet and reticulocyte (RET) parameters, measured by new haematological analyser Sysmex XN and C reactive protein (CRP), for early diagnosis of sepsis during intensive care unit (ICU) stay.

Methods:  The study population consisted of 62 ICU patients, 21 of whom developed sepsis during ICU stay and 41 who did not. The performance for early diagnosing of sepsis was calculated as area under the curve (AUC) of receiver operating characteristics curves analysis.

Results:  Compared with CRP (AUC 0.81), immature platelet fraction (IPF) (AUC 0.82) showed comparable efficiency for identifying the onset of sepsis. The association with the risk of developing sepsis during ICU stay was also assessed. One day before the onset of sepsis, a decreased of RET% was significantly associated with the risk of developing sepsis (OR=0.35, 95% CI 0.14 to 0.87), whereas an increase of IPF absolute value (IPF#) was significantly associated with the risk of developing sepsis (OR=1.13, 95% CI 1.03 to 1.24) 2 days before the onset of sepsis. The value of CRP was not predictive of sepsis at either time points.

Conclusions:  IPF# and RET% may provide valuable clinical information for predicting the risk of developing sepsis, thus allowing early management of patients before the onset of clinically evident systemic infections.

 

The full paper can be accessed using Rotherham NHS Athens password subscribers via this link.  Eligible staff can use this link to register for a Rotherham NHS Athens password.

Controlling catheter-related bloodstream infections through a multicentre educational programme for intensive care units

This paper was published in the Journal of Hospital Infection August issue by Musu and colleagues.

Background:  Bloodstream infections (BSIs) associated with insertion and maintenance of central venous catheters (CR-BSIs) are the most common causes of health care-associated infections in intensive care units (ICUs). They are responsible for increased length of hospital stay and additional health care costs.

Aim:  To investigate whether an educational program addressed at healthcare workers resulted in a significant change in the level and trend of infections.

Methods:  The research was conducted in five Italian ICUs from July 2012 to August 2014. Surveillance and educational interventions to control infections were applied. Compliance with hand hygiene (HH) procedures was assessed via risk relative analysis and 95% interval confidence. Interrupted time series analysis was used to investigate the change in level and trend of infection during the intervention.

Results:  Compliance with HH procedures improved during the intervention for all staff groups, but physicians showed the lowest compliance rates (nurses from 52.4% to 92.1%; nurse aides from 71.0% to 92%; physicians from 71.0% to 92%, p< 0.001). Significant reductions of 21% to 55% in the CR-BSI were observed during the intervention. Small improvements in the monthly infection trend were also observed, but these were not statistically significant.

Conclusions:  An educational programme focussing on general good infection control practice, rather than CVC care bundles resulted in a decreased CR-BSI rate, even if the improvement was not sustained over time. Continuous performance feedback should be provided to promote long-term adherence to guidelines among all health workers.

The full paper can be accessed by subscribers to the “Journal of Hospital Infection” via this link.  Some articles may be available freely without a password.  Library members can order individual articles via the Rotherham NHS Foundation Trust Library and Knowledge Service using the article requests online via this link.

How to better identify patients at high risk of postoperative complications?

This review summarizes historical and more recent scoring systems for predicting patients with increased morbidity and mortality in the postoperative period | Current Opinion in Critical Care

magnifying-glass-1807355_960_720

Purpose of review: Preoperative risk assessment and perioperative factors may help identify patients at increased risk of postoperative complications and allow postoperative management strategies that improve patient outcomes.

Recent findings: Most prediction scores predict postoperative mortality with, at best, moderate accuracy. Scores that incorporate surgery-specific and intraoperative covariates may improve the accuracy of traditional scores. Traditional risk factors including increased ASA physical status score, emergent surgery, intraoperative blood loss and hemodynamic instability are consistently associated with increased mortality using most scoring systems.

Summary: Preoperative clinical risk indices and risk calculators estimate surgical risk with moderate accuracy. Surgery-specific risk calculators are helpful in identifying patients at increased risk of 30-day mortality. Particular attention should be paid to intraoperative hemodynamic instability, blood loss, extent of surgical excision and volume of resection.

Full reference: . & Kelly, B. (2017) How to better identify patients at high risk of postoperative complications? Current Opinion in Critical Care: Published online: 17 August 2017

Critical Care Reviews Newsletter 297 20th August 2017

The 297th Critical Care Reviews Newsletter includes the best critical care research and open access articles from the last week’s the medical literature.  “The highlights of this week’s issue are a randomised controlled trial investigating selepressin in septic shock; an observational trial examining electrical impedance tomography for PEEP; guidelines on the management of acute mesenteric ischemia and the role of the open abdocritcal care reviewsmen in non-trauma patients” Also included are clinical reviews on the intensive care medicine research agenda for airways, invasive and non-invasive mechanical ventilation & oncological patients in the ICU; a non-clinical review on Bayesian analysis; and commentaries on saying goodbye to lectures in medical school and the Nuremberg Code.

 

 

 

The full text of the newsletter can be accessed via this link.

The Critical Care Crisis of Opioid Overdoses in the United States

The August 2017 issue of Annals of the American Thoracic Society included this article by Stevens and colleagues.

Rationale:  Opioid abuse is increasing, but its impact on critical care resources in the United States is unknown.

Objective:  We hypothesized that there would be a rising need for critical care among opioid-associated overdoses in the United States.

Methods:  We analyzed all adult admissions using a retrospective cohort study from 162 hospitals in 44 states discharged between January 1, 2009 – September 31, 2015 to describe the incidence of intensive care unit (ICU) admissions for opioid overdose over this time. Admissions were identified using the Clinical Data Base/Resource ManagerTM of Vizient, Inc, the successor to the University Health System Consortium.

Results:  Our primary outcome was opioid-associated overdose admissions to the ICU. The outcome was defined based on previously validated ICD-9 codes. Our secondary outcomes were in-hospital death and markers of ICU resources. The final cohort included 22,783,628 admissions; 4,145,068 required ICU care. There were 52.4 ICU admissions for overdose per 10,000 ICU admissions over the entire study (95% confidence intervals: 51.8-53.0 per 10,000 ICU admissions). During this time period, opioid overdose admissions requiring intensive care increased 34%, from 44 per 10,000 (95% CI: 43 to 46 per 10,000) to 59 per 10,000 ICU admissions (95% CI: 57 to 61 per 10,000, p<0.0001). The mortality rate of patients with ICU admissions with overdoses averaged 7% (95% CI: 7.0-7.6%) but increased to 10% in 2015 (95% CI: 8.8-10.8%).

Conclusions:  The number of deaths of ICU patients with opioid overdoses increased substantially in the seven years of our study, reflecting increases in both the incidence and mortality of this condition. Our findings raise the need for a national approach to developing safe strategies to care for patients with overdose in the ICU, to providing coordinated resources in the hospital for patients and families, and to helping survivors maintain sobriety on discharge.

The full paper can be accessed by subscribers to the “Annals of the American Thoracic Society” via this link.  Some articles may be available freely without a password.  Library members can order individual articles via the Rotherham NHS Foundation Trust Library and Knowledge Service using the article requests online via this link.

Management of multidrug-resistant Pseudomonas aeruginosa in the intensive care unit: State of the art

This paper by Maraolo et al was published in the August 2017 issue of “Expert review of anti-infective therapy”.

Introduction:  Pseudomonas aeruginosa (PA) is one of the most important causes of healthcare-related infections among Gram-negative bacteria. The best therapeutic approach is controversial, especially for multidrug-resistant (MDR) and extensively drug-resistant (XDR) strains as well as in the setting of most severe patients, such as in the intensive care unit (ICU).

Areas covered:  This article addresses several points. First, the main microbiological aspects of PA, focusing on its wide array of resistance mechanisms. Second, risk factors and the worse outcome linked to MDR-PA infection. Third, the pharmacological peculiarity of ICU patients, that makes the choice of a proper antimicrobial therapy difficult. Eventually, the current therapeutic options against MDR-PA are reviewed, taking into account the main variables that drive antimicrobial optimization in critically ill patients. Literature search was carried out using Pubmed and Web of Science.

Expert commentary: Methodologically rigorous studies are urgently needed to clarify crucial aspects of the treatment against MDR-PA, namely monotherapy versus combination therapy in empiric and targeted settings. In the meanwhile, useful options are represented by newly approved drugs, such as ceftolozane/tazobactam and ceftazidime/avibactam. In critically ill patients, at least as empirical approach, a combination therapy is a prudent choice when a MDR-PA strain is suspected.

The full paper can be accessed by subscribers to “Expert Review of Anti-Infective Therapy” via this link.  Some articles may be available freely without a password.  Library members can order individual articles via the Rotherham NHS Foundation Trust Library and Knowledge Service using the article requests online via this link.