Features of Adult Hyperammonemia Not Due to Liver Failure in the ICU

This article by Sakusic and colleagues was published in Critical Care Medicine 2018 edition.
Objectives:  To evaluate the epidemiology of hyperammonemia unrelated to liver failure in the critical care setting.
Design:  Retrospective case series.
Setting:  Critically ill patients admitted to ICUs at Mayo Clinic, Rochester, MN (medical ICU, two mixed medical-surgical ICUs, coronary care unit, or the cardiosurgical ICU) between July 1, 2004, and October 31, 2015.
Patients:  Adult critically ill patients with hyperammonemia not related to acute or chronic liver failure. We excluded patients with diagnosis of moderate or severe liver disease, hyperbilirubinemia, and patients who denied the use of their medical records.
Measurements and main results:  Of 3,908 ICU patients with hyperammonemia, 167 (4.5%) had no evidence of acute or chronic liver failure. One-hundred one patients (60.5%) were male with median age of 65.7 years (interquartile range, 50-74.5 yr) and median serum ammonia level of 68 µg/dL (interquartile range, 58-87 µg/dL). Acute encephalopathy was present in 119 patients (71%). Predisposing conditions included malnutrition 27 (16%), gastric bypass six (3.6%), total parenteral nutrition four (2.4%); exposure to valproic acid 17 (10%); status epilepticus 11 (6.6%), high tumour burden 19 (11.3%), and renal failure 82 (49.1%). Urea cycle defects were diagnosed in seven patients (4.1%). Hospital mortality was high (30%), and median ammonia level was higher among the nonsurvivors (74 vs 67 µg/dL; p = 0.05). Deaths were more likely in hyperammonemic patients who were older (p = 0.016), had greater illness severity (higher Acute Physiology and Chronic Health Evaluation III score, p < 0.01), malignancy (p < 0.01), and solid organ transplantation (p = 0.04), whereas seizure disorder was more common in survivors (p = 0.02). After adjustment, serum ammonia level was not associated with increased mortality.
Conclusions:  Hyperammonemia occurs in a substantial minority of critically ill patients without liver failure. These patients have a poor prognosis, although ammonia level per se is not independently associated with mortality. Serum ammonia should be measured when risk factors are present, such as nutritional deficiencies and protein refeeding, treatment with valproic acid, high tumour burden, and known or suspected urea cycle abnormalities.
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Modes of mechanical ventilation vary between hospitals and intensive care units within a university healthcare system: a retrospective observational study

This research by Jabaley et al was published in the July 2018 issue of BMC Research Notes.
Objective:  As evidence-based guidance to aid clinicians with mechanical ventilation mode selection is scant, we sought to characterize the epidemiology thereof within a university healthcare system and hypothesized that nonconforming approaches could be readily identified. We conducted an exploratory retrospective observational database study of routinely recorded mechanical ventilation parameters between January 1, 2010 and December 31, 2016 from 12 intensive care units. Mode epoch count proportions were examined using Chi squared and Fisher exact tests as appropriate on an inter-unit basis with outlier detection for two test cases via post hoc pairwise analyses of a binomial regression model.  Results:  Final analysis included 559,734 mode epoch values. Significant heterogeneity was demonstrated between individual units (P < 0.05 for all comparisons). One unit demonstrated heightened utilization of high-frequency oscillatory ventilation, and three units demonstrated frequent synchronized intermittent mandatory ventilation utilization. Assist control ventilation was the most commonly recorded mode (51%), followed by adaptive support ventilation (23.1%). Volume-controlled modes were about twice as common as pressure-controlled modes (64.4% versus 35.6%). Our methodology provides a means by which to characterize the epidemiology of mechanical ventilation approaches and identify nonconforming practices. The observed variability warrants further clinical study about contributors and the impact on relevant outcomes.

The full text of this article in BMC Research Notes is available via this link.

Critical Care Reviews Newsletter 343 8th July 2018

The 343rd Critical Care Reviews Newsletter, brings 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 comparing terlipressin with norepinephrine in septic shock & adrenaline with noradrenaline in cardiogenic shock; systematic reviews and meta analyses investigating steroids in sepsis & perioperative goal-directed therapy, plus observational studies on premorbid functional status in ICU patients aged 80 years or older, hemoglobin concentration variations to predict significant hemorrhage in the early phase of trauma, & unfavourable outcomes in patients with WFNS grade I aneurysmal subarachnoid haemorrhage.  There are also guidelines on the management of ARDS from the Intensive Care Society & a research priority update from the surviving sepsis campaign; as well as excellent narrative reviews on vasoplegic shock, dry drowning & coagulation in liver disease”
The full text of newsletter 343 can be found via this link

Critical Care Reviews Newsletter 342 24th June 2018

The Critical Care Reviews Newsletter provides the best critical care research and open access articles from across the medical literature in the last week.  “The highlights of this week’s edition are systematic reviews and meta analyses on recruitment maneuvers, out-of-hours discharge from the ICU, and early enteral nutrition within 24 hours of ICU admission, plus observational studies on the electrolarynx for enabling communication in the chronically critically ill and the results of the NAP6 audit on anaesthesia, surgery, and life-threatening allergic reactions. There are also narrative reviews on the assessment of hypovolaemia in the critically ill, linezolid and ECMO in poisoning; editorials on hydrocortisone in septic shock, between hypoxia or hyperoxia and prone positioning for ARDS, as well as commentaries on the central nervous system efficacy of antimicrobials, burnout and transthoracic echocardiography in sepsis. In news, the European Medicines Agency has bizarrely approved hydroxyethyl starch solutions, a decision which will raise many eyebrows given their lack of efficacy and proven harmful effects.”
The full text of newsletter 342 can be found via this link

June 2018 Issue of “Intensive Care Medicine” Volume 44 Number 6

intensive-care-medicine“Intensive Care Medicine” is a publication for the communication and exchange of current work and ideas in intensive care medicine.  To access the latest issue’s contents page follow this link. 
Articles in this edition include “Epinephrine and short-term survival in cardiogenic shock: an individual data meta-analysis of 2583 patients”, “A state of the art review on optimal practices to prevent, recognize, and manage complications associated with intravascular devices in the critically ill” and “The relationship between ICU hypotension and in-hospital mortality and morbidity in septic patients”
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Intensive care doctors’ preferences for arterial oxygen tension levels in mechanically ventilated patients

This article by Schjorring and others was published in Acta Anaesthesioligica Scandinavica in June 2018.
Background:  Oxygen is liberally administered in intensive care units (ICUs). Nevertheless, ICU doctors’ preferences for supplementing oxygen are inadequately described. The aim was to identify ICU doctors’ preferences for arterial oxygenation levels in mechanically ventilated adult ICU patients.
Methods:  In April to August 2016, an online multiple-choice 17-part-questionnaire was distributed to 1080 ICU doctors in seven Northern European countries. Repeated reminder e-mails were sent. The study ended in October 2016.
Results:  The response rate was 63%. When evaluating oxygenation 52% of respondents rated arterial oxygen tension (PaO2 ) the most important parameter; 24% a combination of PaO2 and arterial oxygen saturation (SaO2 ); and 23% preferred SaO2 . Increasing, decreasing or not changing a default fraction of inspired oxygen of 0.50 showed preferences for a PaO2 around 8 kPa in patients with chronic obstructive pulmonary disease, a PaO2 around 10 kPa in patients with healthy lungs, acute respiratory distress syndrome or sepsis, and a PaO2 around 12 kPa in patients with cardiac or cerebral ischaemia. Eighty per cent would accept a PaO2 of 8 kPa or lower and 77% would accept a PaO2 of 12 kPa or higher in a clinical trial of oxygenation targets.
Conclusion:  Intensive care unit doctors preferred PaO2 to SaO2 in monitoring oxygen treatment when peripheral oxygen saturation was not included in the question. The identification of PaO2 as the preferred target and the thorough clarification of preferences are important when ascertaining optimal oxygenation targets. In particular when designing future clinical trials of higher vs lower oxygenation targets in ICU patients.
To access the full text of these articles via the journal’s homepage you require a personal subscription to the journal.  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.

Interruptions During Senior Nurse Handover in the Intensive Care Unit: A Quality Improvement Study

This article by Spooner and colleagues was published in June 2018 issue of the Journal of Nursing Care Quality.
Background:  Interruptions during handover may compromise continuity of care and patient safety.
Local Problem:  Interruptions occur frequently during handovers in the intensive care unit.
Methods:  A quality improvement study was undertaken to improve nursing team leader handover processes. The frequency, source, and reason interruptions occurred were recorded before and after a handover intervention.
Interventions:  The intervention involved relocating handover from the desk to bedside and using a printed version of an evidence-based electronic minimum data set. These strategies were supported by education, champions, reminders, and audit and feedback.
Results:  Forty handovers were audio taped before, and 49 were observed 3 months following the intervention. Sixty-four interruptions occurred before and 52 after the intervention, but this difference was not statistically significant. Team leaders were frequently interrupted by nurses discussing personal or work-specific matters before and after the intervention.
Conclusions:  Further work is required to reduce interruptions that do not benefit patient care.
The full text of this article is available via this link to the journal’s homepage if you have a personal subscription to the journal.  Library members can order individual articles via the Rotherham NHS Foundation Trust Library and Knowledge Service using the article requests online via this link.